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Zamoner SMS, Takase HM, Riyuzo MC, Caramori JCT, de Andrade LGM. Safety of cinacalcet in children and adolescents with chronic kidney disease-mineral bone disorder: systematic review and proportional meta-analysis of case series. Int Urol Nephrol 2024; 56:1669-1676. [PMID: 37964112 PMCID: PMC11001724 DOI: 10.1007/s11255-023-03844-2] [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] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 10/08/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND Mineral and bone disease in children with chronic kidney disease can cause abnormalities in calcium, phosphorus, parathyroid hormone, and vitamin D and when left untreated can result in impaired growth, bone deformities, fractures, and vascular calcification. Cinacalcet is a calcimimetic widely used as a therapy to reduce parathyroid hormone levels in the adult population, with hypocalcemia among its side effects. The analysis of safety in the pediatric population is questioned due to the scarcity of randomized clinical trials in this group. OBJECTIVE To assess the onset of symptomatic hypocalcemia or other adverse events (serious or non-serious) with the use of cinacalcet in children and adolescents with mineral and bone disorder in chronic kidney disease. DATA SOURCES AND STUDY ELIGIBILITY CRITERIA The bibliographic search identified 2699 references from 1927 to August/2023 (57 LILACS, 44 Web of Science, 686 PubMed, 131 Cochrane, 1246 Scopus, 535 Embase). Four references were added from the bibliography of articles found and 12 references from the gray literature (Clinical Trials). Of the 77 studies analyzed in full, 68 were excluded because they did not meet the following criteria: population, types of studies, medication, publication types and 1 article that did not present results (gray literature). PARTICIPANTS AND INTERVENTIONS There were 149 patients aged 0-18 years old with Chronic Kidney Disease and mineral bone disorder who received cinacalcet. STUDY APPRAISAL AND SYNTHESIS METHODS Nine eligible studies were examined for study type, size, intervention, and reported outcomes. RESULTS There was an incidence of 0.2% of fatal adverse events and 16% of serious adverse events (p < 0.01 and I2 = 69%), in addition to 10.7% of hypocalcemia, totaling 45.7% of total adverse events. LIMITATIONS There was a bias in demographic information and clinical characteristics of patients in about 50% of the studies and the majority of the studies were case series. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS If used in the pediatric population, the calcimimetic cinacalcet should be carefully monitored for serum calcium levels and attention to possible adverse events, especially in children under 50 months. SYSTEMATIC REVIEW REGISTRATION NUMBER (PROSPERO REGISTER) CRD42019132809.
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Affiliation(s)
- Soraya Mayumi Sasaoka Zamoner
- Botucatu School of Medicine, Pediatrics Department - Pediatric Nephrology, University São Paulo State-UNESP, District of Rubiao Junior, Botucatu, SP, 18618-970, Brazil.
- Clinics Hospital - Botucatu School of Medicine, District of Rubiao Junior, Botucatu, SP, 18618-970, Brazil.
| | - Henrique Mochida Takase
- Botucatu School of Medicine, Pediatrics Department - Pediatric Nephrology, University São Paulo State-UNESP, District of Rubiao Junior, Botucatu, SP, 18618-970, Brazil
- Clinics Hospital - Botucatu School of Medicine, District of Rubiao Junior, Botucatu, SP, 18618-970, Brazil
| | - Marcia Camegaçava Riyuzo
- Botucatu School of Medicine, Pediatrics Department - Pediatric Nephrology, University São Paulo State-UNESP, District of Rubiao Junior, Botucatu, SP, 18618-970, Brazil
- Clinics Hospital - Botucatu School of Medicine, District of Rubiao Junior, Botucatu, SP, 18618-970, Brazil
| | - Jacqueline Costa Teixeira Caramori
- Botucatu School of Medicine, Internal Medicine Department - Nephrology, University São Paulo State-UNESP, District of Rubiao Junior, Botucatu, SP, 18618-970, Brazil
- Clinics Hospital - Botucatu School of Medicine, District of Rubiao Junior, Botucatu, SP, 18618-970, Brazil
| | - Luis Gustavo Modelli de Andrade
- Botucatu School of Medicine, Internal Medicine Department - Nephrology, University São Paulo State-UNESP, District of Rubiao Junior, Botucatu, SP, 18618-970, Brazil
- Clinics Hospital - Botucatu School of Medicine, District of Rubiao Junior, Botucatu, SP, 18618-970, Brazil
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Pazianas M, Miller PD. The rationale for intermittent administration of PTH in the management of mineral and bone disorder of chronic kidney disease. J Nephrol 2024; 37:337-342. [PMID: 37171706 DOI: 10.1007/s40620-023-01642-8] [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] [Subscribe] [Scholar Register] [Accepted: 04/04/2023] [Indexed: 05/13/2023]
Abstract
A major complication of chronic kidney disease is the derangement of mineral metabolism, leading to increased risk of fractures and cardiovascular mortality. Current therapeutic regimens are focused on reducing parathyroid hormone levels caused by secondary hyperparathyroidism, and the active vitamin D metabolite l,25(OH)2D, with limited success. It may be a more effective approach, however, if we could target the delayed response of parathyroid hormone in the early retention of phosphate following loss of renal function.We propose intermittent administration (even in stage 2 chronic kidney disease) of parathyroid hormone, known for its bone anabolic effects compared to the catabolic effects of the continuously elevated parathyroid hormone associated with the hyperparathyroid state, to mitigate the retention of phosphate. This approach may prevent the compensatory responses of the other two major calcium- and phosphate-regulating hormones (FGF-23 and l,25(OH)2D) that lead to further worsening of the derangement of mineral metabolism.In addition to its strong theoretical basis, there are data supporting the need for further research focused on the use of intermittent parathyroid hormone in the management of chronic kidney disease-mineral bone disorder.
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Affiliation(s)
- Michael Pazianas
- Institute of Musculoskeletal Sciences, Oxford University, Oxford, OX3 7LD, UK.
| | - Paul D Miller
- University of Colorado Health Sciences Center, Denver, CO, 80262, USA
- Colorado Center for Bone Health, Lakewood, CO, USA
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Teh JW, Mac Gearailt C, Lappin DWP. Post-Transplant Bone Disease in Kidney Transplant Recipients: Diagnosis and Management. Int J Mol Sci 2024; 25:1859. [PMID: 38339137 PMCID: PMC10856017 DOI: 10.3390/ijms25031859] [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] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 01/24/2024] [Accepted: 02/01/2024] [Indexed: 02/12/2024] Open
Abstract
Kidney transplantation is the preferred gold standard modality of treatment for kidney failure. Bone disease after kidney transplantation is highly prevalent in patients living with a kidney transplant and is associated with high rates of hip fractures. Fractures are associated with increased healthcare costs, morbidity and mortality. Post-transplant bone disease (PTBD) includes renal osteodystrophy, osteoporosis, osteonecrosis and bone fractures. PTBD is complex as it encompasses pre-existing chronic kidney disease-mineral bone disease and compounding factors after transplantation, including the use of immunosuppression and the development of de novo bone disease. After transplantation, the persistence of secondary and tertiary hyperparathyroidism, renal osteodystrophy, relative vitamin D deficiency and high levels of fibroblast growth factor-23 contribute to post-transplant bone disease. Risk assessment includes identifying both general risk factors and kidney-specific risk factors. Diagnosis is complex as the gold standard bone biopsy with double-tetracycline labelling to diagnose the PTBD subtype is not always readily available. Therefore, alternative diagnostic tools may be used to aid its diagnosis. Both non-pharmacological and pharmacological therapy can be employed to treat PTBD. In this review, we will discuss pathophysiology, risk assessment, diagnosis and management strategies to manage PTBD after kidney transplantation.
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Affiliation(s)
- Jia Wei Teh
- Department of Nephrology, Galway University Hospital, H91 YR71 Galway, Ireland
| | - Conall Mac Gearailt
- Department of Rheumatology, Galway University Hospital, H91 YR71 Galway, Ireland
| | - David W. P. Lappin
- Department of Nephrology, Galway University Hospital, H91 YR71 Galway, Ireland
- School of Medicine, University of Galway, H91 TK33 Galway, Ireland
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Evenepoel P, Jørgensen HS, Bover J, Davenport A, Bacchetta J, Haarhaus M, Hansen D, Gracia-Iguacel C, Ketteler M, McAlister L, White E, Mazzaferro S, Vervloet M, Shroff R. Recommended calcium intake in adults and children with chronic kidney disease-a European consensus statement. Nephrol Dial Transplant 2024; 39:341-366. [PMID: 37697718 DOI: 10.1093/ndt/gfad185] [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] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Indexed: 09/13/2023] Open
Abstract
Mineral and bone disorders (MBD) are common in patients with chronic kidney disease (CKD), contributing to significant morbidity and mortality. For several decades, the first-line approach to controlling hyperparathyroidism in CKD was by exogenous calcium loading. Since the turn of the millennium, however, a growing awareness of vascular calcification risk has led to a paradigm shift in management and a move away from calcium-based phosphate binders. As a consequence, contemporary CKD patients may be at risk of a negative calcium balance, which, in turn, may compromise bone health, contributing to renal bone disease and increased fracture risk. A calcium intake below a certain threshold may be as problematic as a high intake, worsening the MBD syndrome of CKD, but is not addressed in current clinical practice guidelines. The CKD-MBD and European Renal Nutrition working groups of the European Renal Association (ERA), together with the CKD-MBD and Dialysis working groups of the European Society for Pediatric Nephrology (ESPN), developed key evidence points and clinical practice points on calcium management in children and adults with CKD across stages of disease. These were reviewed by a Delphi panel consisting of ERA and ESPN working groups members. The main clinical practice points include a suggested total calcium intake from diet and medications of 800-1000 mg/day and not exceeding 1500 mg/day to maintain a neutral calcium balance in adults with CKD. In children with CKD, total calcium intake should be kept within the age-appropriate normal range. These statements provide information and may assist in decision-making, but in the absence of high-level evidence must be carefully considered and adapted to individual patient needs.
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Affiliation(s)
- Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium
- Department of Medicine, Division of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Hanne Skou Jørgensen
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark
| | - Jordi Bover
- Department of Nephrology, University Hospital Germans Trias i Pujol, Barcelona, Catalonia, Spain
- REMAR-IGTP Group, Germans Trias i Pujol Research Institute, Can Ruti Campus, Barcelona, Catalonia, Spain
| | - Andrew Davenport
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
| | - Justine Bacchetta
- Pediatric Nephrology Rheumatology and Dermatology Unit, Reference Center for Rare Renal Diseases, ORKID and ERK-Net networks, Lyon University Hospital, Bron, France
- Lyon Est Medical School, INSERM1033 Research Unit, Claude Bernard Lyon 1 University, Lyon, France
| | - Mathias Haarhaus
- Division of Renal Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Diaverum Sweden, Malmö, Sweden
| | - Ditte Hansen
- Department of Nephrology, Copenhagen University Hospital-Herlev, Copenhagen
- Institute of Clinical Medicine, University of Copenhagen, Denmark
| | - Carolina Gracia-Iguacel
- Department of Renal Medicine, IIS-Fundación Jiménez Díaz UAM University Hospital, Madrid, Spain
| | - Markus Ketteler
- Department of General Internal Medicine and Nephrology, Robert-Bosch Hospital, Stuttgart, Germany
| | - Louise McAlister
- Dietetic Team, UCL Great Ormond Street Hospital for Children and University College London, London, UK
| | - Emily White
- Dietetic Team, Royal Free Hospital, University College London, London, UK
| | - Sandro Mazzaferro
- Department of Translation and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Marc Vervloet
- Amsterdam Cardiovascular Sciences, Amsterdam UMC, The Netherlands
- Department of Nephrology, Amsterdam UMC, The Netherlands
| | - Rukshana Shroff
- Renal Unit, UCL Great Ormond Street Hospital for Children, London, UK
- Institute of Child Health, University College London, London, UK
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Fu R, Meng K, Zhang R, Du X, Jiao J. Bone marrow-derived exosomes promote inflammation and osteoclast differentiation in high-turnover renal osteodystrophy. Ren Fail 2023; 45:2264396. [PMID: 37870853 PMCID: PMC11001343 DOI: 10.1080/0886022x.2023.2264396] [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] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 09/23/2023] [Indexed: 10/24/2023] Open
Abstract
Introduction: Renal osteodystrophy (ROD) is a type of bone metabolic disorder in patients with chronic kidney disease (CKD). Inflammation is associated with bone loss in ROD. However, its precise mechanism has not yet been elucidated. The present study was conducted to investigate whether exosomes (Exos) in bone marrow (BM) are involved in the pathogenesis of high-turnover ROD.Methods: Bone mass, osteoclast number, and pro-inflammatory cytokines levels of BM supernatant were detected in adenine-induced ROD rats. The effect of Exos derived from BM (BM-Exos) of ROD (ROD-Exos) on inflammatory genes and osteoclast differentiation of BM-derived macrophages (BMMs) were further examined. Then, exosomal miRNA sequencing was performed and an miRNA-mRNA-pathway network was constructed.Results: we found increased osteoclasts and decreased bone mass in ROD rats, as well as inflammatory activation in the BM niche. Furthermore, BMMs from ROD rats displayed overproduction of proinflammatory cytokines and increased osteoclast differentiation, accompanied by nuclear factor κB (NF-κB) signaling activation. Mechanistically, we found that ROD-Exos activates NF-κB signaling to promote the release of proinflammatory cytokines and increase osteoclast differentiation of BMMs. Meanwhile, a total of 24 differentially expressed miRNAs were identified between BM-Exos from ROD and normal control (NC). The miRNA-mRNA-pathway network suggests that rno-miR-9a-5p, rno-miR-133a-3p, rno-miR-30c-5p, rno-miR-206-3p, and rno-miR-17-5p might play pivotal roles in inflammation and osteoclast differentiation. Additionally, we validated that the expression of miR-9a-5p is upregulated in ROD-Exos.Conclusion: The BM niche of ROD alters the miRNA cargo of BM-Exos to promote inflammation and osteoclast differentiation of BMMs, at least partially contributing to the pathogenesis of high-turnover ROD.
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Affiliation(s)
- Rao Fu
- Department of Nephrology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Kexin Meng
- Department of Nephrology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Rui Zhang
- Department of Nephrology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xuanyi Du
- Department of Nephrology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jundong Jiao
- Department of Nephrology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
- Institute of Nephrology, Harbin Medical University, Harbin, China
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Zhang L, Adu IK, Zhang H, Wang J. The WNT/β-catenin system in chronic kidney disease-mineral bone disorder syndrome. Int Urol Nephrol 2023; 55:2527-2538. [PMID: 36964322 DOI: 10.1007/s11255-023-03569-2] [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] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 03/18/2023] [Indexed: 03/26/2023]
Abstract
BACKGROUND The WNT/β-catenin system is an evolutionarily conserved signaling pathway that plays a crucial role in morphogenesis and cell tissue formation during embryogenesis. Although usually suppressed in adulthood, it can be reactivated during organ damage and regeneration. Transient activation of the WNT/β-catenin pathway stimulates tissue regeneration after acute kidney injury, while persistent (uncontrolled) activation can promote the development of chronic kidney disease (CKD). CKD-MBD is a clinical syndrome that develops with systemic mineral and bone metabolism disorders caused by CKD, characterized by abnormal bone mineral metabolism and/or extraosseous calcification, as well as cardiovascular disease associated with CKD, including vascular stiffness and calcification. OBJECTIVE This paper aims to comprehensively review the WNT/β-catenin signaling pathway in relation to CKD-MBD, focusing on its components, regulatory molecules, and regulatory mechanisms. Additionally, this review highlights the challenges and opportunities for using small molecular compounds to target the WNT/β-catenin signaling pathway in CKD-MBD therapy. METHODS We conducted a comprehensive literature review using various scientific databases, including PubMed, Scopus, and Web of Science, to identify relevant articles. We searched for articles that discussed the WNT/β-catenin signaling pathway, CKD-MBD, and their relationship. We also reviewed articles that discussed the components of the WNT/β-catenin signaling pathway, its regulatory molecules, and regulatory mechanisms. RESULTS The WNT/β-catenin signaling pathway plays a crucial role in CKD-MBD by promoting vascular calcification and bone mineral metabolism disorders. The pathway's components include WNT ligands, Frizzled receptors, and LRP5/6 co-receptors, which initiate downstream signaling cascades leading to the activation of β-catenin. Several regulatory molecules, including GSK-3β, APC, and Axin, modulate β-catenin activation. The WNT/β-catenin signaling pathway also interacts with other signaling pathways, such as the BMP pathway, to regulate CKD-MBD. CONCLUSIONS The WNT/β-catenin signaling pathway is a potential therapeutic target for CKD-MBD. Small molecular compounds that target the components or regulatory molecules of the pathway may provide a promising approach to treat CKD-MBD. However, more research is needed to identify safe and effective compounds and to determine the optimal dosages and treatment regimens.
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Affiliation(s)
- Lingbo Zhang
- The School of Basic Medicine, Health Science Center, Yangtze University, Jingzhou, People's Republic of China
| | - Isaac Kumi Adu
- The School of Basic Medicine, Health Science Center, Yangtze University, Jingzhou, People's Republic of China
- Department of Internal Medicine, The Second Hospital of Jingzhou and the Affiliated Hospital of Hubei College of Chinese Medicine, Jingzhou, People's Republic of China
- Department of Internal Medicine, Kings and Queens University College and Teaching Hospital, Akosombo, Ghana
| | - Haifeng Zhang
- Department of Internal Medicine, The Second Hospital of Jingzhou and the Affiliated Hospital of Hubei College of Chinese Medicine, Jingzhou, People's Republic of China
| | - Jiancheng Wang
- Department of Internal Medicine, The Second Hospital of Jingzhou and the Affiliated Hospital of Hubei College of Chinese Medicine, Jingzhou, People's Republic of China.
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Abstract
Two decades ago, Kidney Disease: Improving Global Outcomes coined the term chronic kidney disease-mineral and bone disorder (CKD-MBD) to describe the syndrome of biochemical, bone and extra-skeletal calcification abnormalities that occur in patients with CKD. CKD-MBD is a prevalent complication and contributes to the excessively high burden of fractures and cardiovascular disease, loss of quality of life and premature mortality in patients with CKD. Thus far, therapy has focused primarily on phosphate retention, abnormal vitamin D metabolism and parathyroid hormone disturbances, but these strategies have largely proved unsuccessful, thus calling for paradigm-shifting concepts and innovative therapeutic approaches. Interorgan crosstalk is increasingly acknowledged to have an important role in health and disease. Accordingly, mounting evidence suggests a role for both the immune system and the gut microbiome in bone and vascular biology. Gut dysbiosis, compromised gut epithelial barrier and immune cell dysfunction are prominent features of the uraemic milieu. These alterations might contribute to the inflammatory state observed in CKD and could have a central role in the pathogenesis of CKD-MBD. The emerging fields of osteoimmunology and osteomicrobiology add another level of complexity to the pathogenesis of CKD-MBD, but also create novel therapeutic opportunities.
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Affiliation(s)
- Pieter Evenepoel
- Laboratory of Nephrology, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Herestraat, Leuven, Belgium.
| | - Peter Stenvinkel
- Department of Renal Medicine M99, Karolinska University Hospital, Stockholm, Sweden
| | - Catherine Shanahan
- British Heart Foundation Centre of Excellence, School of Cardiovascular and Metabolic Medicine and Sciences, King's College London, London, UK
| | - Roberto Pacifici
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory Microbiome Research Center, and Immunology and Molecular Pathogenesis Program, Emory University, Atlanta, GA, USA
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Cejka D, Wakolbinger-Habel R, Zitt E, Fahrleitner-Pammer A, Amrein K, Dimai HP, Muschitz C. [Diagnosis and treatment of osteoporosis in patients with chronic kidney disease : Joint guidelines of the Austrian Society for Bone and Mineral Research (ÖGKM), the Austrian Society of Physical and Rehabilitation Medicine (ÖGPMR) and the Austrian Society of Nephrology (ÖGN)]. Wien Med Wochenschr 2023; 173:299-318. [PMID: 36542221 PMCID: PMC10516794 DOI: 10.1007/s10354-022-00989-0] [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] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 11/09/2022] [Indexed: 12/24/2022]
Abstract
DEFINITION AND EPIDEMIOLOGY Chronic kidney disease (CKD): abnormalities of kidney structure or function, present for over 3 months. Staging of CKD is based on GFR and albuminuria (not graded). Osteoporosis: compromised bone strength (low bone mass, disturbance of microarchitecture) predisposing to fracture. By definition, osteoporosis is diagnosed if the bone mineral density T‑score is ≤ -2.5. Furthermore, osteoporosis is diagnosed if a low-trauma (inadequate trauma) fracture occurs, irrespective of the measured T‑score (not graded). The prevalence of osteoporosis, osteoporotic fractures and CKD is increasing worldwide (not graded). PATHOPHYSIOLOGY, DIAGNOSIS AND TREATMENT OF CHRONIC KIDNEY DISEASE-MINERAL AND BONE DISORDER (CKD-MBD): Definition of CKD-MBD: a systemic disorder of mineral and bone metabolism due to CKD manifested by either one or a combination of the following: abnormalities of calcium, phosphorus, PTH, or vitamin D metabolism; renal osteodystrophy; vascular calcification (not graded). Increased, normal or decreased bone turnover can be found in renal osteodystrophy (not graded). Depending on CKD stage, routine monitoring of calcium, phosphorus, alkaline phosphatase, PTH and 25-OH-vitamin D is recommended (2C). Recommendations for treatment of CKD-MBD: Avoid hypercalcemia (1C). In cases of hyperphosphatemia, lower phosphorus towards normal range (2C). Keep PTH within or slightly above normal range (2D). Vitamin D deficiency should be avoided and treated when diagnosed (1C). DIAGNOSIS AND RISK STRATIFICATION OF OSTEOPOROSIS IN CKD Densitometry (using dual X‑ray absorptiometry, DXA): low T‑score correlates with increased fracture risk across all stages of CKD (not graded). A decrease of the T‑score by 1 unit approximately doubles the risk for osteoporotic fracture (not graded). A T-score ≥ -2.5 does not exclude osteoporosis (not graded). Bone mineral density of the lumbar spine measured by DXA can be increased and therefore should not be used for the diagnosis or monitoring of osteoporosis in the presence of aortic calcification, osteophytes or vertebral fracture (not graded). FRAX can be used to aid fracture risk estimation in all stages of CKD (1C). Bone turnover markers can be measured in individual cases to monitor treatment (2D). Bone biopsy may be considered in individual cases, especially in patients with CKD G5 (eGFR < 15 ml/min/1.73 m2) or CKD 5D (dialysis). SPECIFIC TREATMENT OF OSTEOPOROSIS IN PATIENTS WITH CKD Hypocalcemia should be treated and serum calcium normalized before initiating osteoporosis therapy (1C). CKD G1-G2 (eGFR ≥ 60 ml/min/1.73 m2): treat osteoporosis as recommended for the general population (1A). CKD G3-G5D (eGFR < 60 ml/min/1.73 m2 to dialysis): treat CKD-MBD first before initiating osteoporosis treatment (2C). CKD G3 (eGFR 30-59 ml/min/1.73 m2) with PTH within normal limits and osteoporotic fracture and/or high fracture risk according to FRAX: treat osteoporosis as recommended for the general population (2B). CKD G4-5 (eGFR < 30 ml/min/1.73 m2) with osteoporotic fracture (secondary prevention): Individualized treatment of osteoporosis is recommended (2C). CKD G4-5 (eGFR < 30 ml/min/1.73 m2) and high fracture risk (e.g. FRAX score > 20% for a major osteoporotic fracture or > 5% for hip fracture) but without prevalent osteoporotic fracture (primary prevention): treatment of osteoporosis may be considered and initiated individually (2D). CKD G4-5D (eGFR < 30 ml/min/1.73 m2 to dialysis): Calcium should be measured 1-2 weeks after initiation of antiresorptive therapy (1C). PHYSICAL MEDICINE AND REHABILITATION Resistance training prioritizing major muscle groups thrice weekly (1B). Aerobic exercise training for 40 min four times per week (1B). Coordination and balance exercises thrice weekly (1B). Flexibility exercise 3-7 times per week (1B).
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Affiliation(s)
- Daniel Cejka
- Abteilung für Innere Medizin III, Nieren- und Hochdruckerkrankungen, Transplantationsmedizin, Rheumatologie, Akutgeriatrie, Ordensklinikum Linz – Krankenhaus der Elisabethinen, Fadingerstr. 1, 4020 Linz, Österreich
| | - Robert Wakolbinger-Habel
- Department of Physical and Rehabilitation Medicine (PRM), Vienna Healthcare Group – Clinic Donaustadt, Langobardenstr. 122, 1220 Wien, Österreich
| | - Emanuel Zitt
- Department of Internal Medicine 3 (Nephrology and Dialysis), Feldkirch Academic Teaching Hospital, Feldkirch, Österreich
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Feldkirch, Österreich
- Agency for Preventive and Social Medicine (aks), Bregenz, Österreich
| | - Astrid Fahrleitner-Pammer
- Division of Endocrinology and Diabetology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Österreich
| | - Karin Amrein
- Division of Endocrinology and Diabetology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Österreich
| | - Hans Peter Dimai
- Division of Endocrinology and Diabetology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Österreich
| | - Christian Muschitz
- Medical Department II – VINFORCE, St. Vincent Hospital Vienna (Barmherzige Schwestern Krankenhaus Wien), Stumpergasse 13, 1060 Wien, Österreich
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Elder GJ. Current Status of Mineral and Bone Disorders in Transplant Recipients. Transplantation 2023; 107:2107-2119. [PMID: 36788445 DOI: 10.1097/tp.0000000000004538] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Most patients with end-stage kidney disease undergoing kidney transplantation are affected by the chronic kidney disease-mineral and bone disorder. This entity encompasses laboratory abnormalities, calcification of soft tissues, and the bone abnormalities of renal osteodystrophy that together result in an increased risk of fracture, cardiovascular events, and mortality. Although many biochemical disturbances associated with end-stage kidney disease improve in the first year after transplantation, hyperparathyroidism commonly persists, and residual changes of renal osteodystrophy are slow to resolve. When superimposed on common, traditional risk factors, post-transplant glucocorticoid treatment, the possibility of tubular disturbances and post-transplant chronic kidney disease, rates of incident fracture remain high. This review examines hormonal and biochemical changes before and after kidney transplantation, fracture risk assessment tools and imaging modalities, a staged approach to management and concerns associated with antiresorptive and anabolic therapies. A multidisciplinary approach is proposed as the best means to improve patient-level outcomes.
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Affiliation(s)
- Grahame J Elder
- Department of Renal Medicine, Westmead Hospital, Sydney, Australia
- Skeletal Biology Program, Garvan Institute of Medical Research, Sydney, Australia
- School of Medicine, University of Notre Dame, Sydney, Australia
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Bacchetta J, Schmitt CP, Bakkaloglu SA, Cleghorn S, Leifheit-Nestler M, Prytula A, Ranchin B, Schön A, Stabouli S, Van de Walle J, Vidal E, Haffner D, Shroff R. Diagnosis and management of mineral and bone disorders in infants with CKD: clinical practice points from the ESPN CKD-MBD and Dialysis working groups and the Pediatric Renal Nutrition Taskforce. Pediatr Nephrol 2023; 38:3163-3181. [PMID: 36786859 PMCID: PMC10432337 DOI: 10.1007/s00467-022-05825-6] [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: 08/05/2022] [Revised: 10/19/2022] [Accepted: 11/09/2022] [Indexed: 02/15/2023]
Abstract
BACKGROUND Infants with chronic kidney disease (CKD) form a vulnerable population who are highly prone to mineral and bone disorders (MBD) including biochemical abnormalities, growth retardation, bone deformities, and fractures. We present a position paper on the diagnosis and management of CKD-MBD in infants based on available evidence and the opinion of experts from the European Society for Paediatric Nephrology (ESPN) CKD-MBD and Dialysis working groups and the Pediatric Renal Nutrition Taskforce. METHODS PICO (Patient, Intervention, Comparator, Outcomes) questions were generated, and relevant literature searches performed covering a population of infants below 2 years of age with CKD stages 2-5 or on dialysis. Clinical practice points (CPPs) were developed and leveled using the American Academy of Pediatrics grading matrix. A Delphi consensus approach was followed. RESULTS We present 34 CPPs for diagnosis and management of CKD-MBD in infants, including dietary control of calcium and phosphate, and medications to prevent and treat CKD-MBD (native and active vitamin D, calcium supplementation, phosphate binders). CONCLUSION As there are few high-quality studies in this field, the strength of most statements is weak to moderate, and may need to be adapted to individual patient needs by the treating physician. Research recommendations to study key outcome measures in this unique population are suggested. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Justine Bacchetta
- Reference Center for Rare Renal Diseases, Reference Center for Rare Diseases of Calcium and Phosphate Metabolism, Pediatric Nephrology Rheumatology and Dermatology Unit, Hopital Femme Mère Enfant, Boulevard Pinel, 69677 Bron, France
- INSERM 1033 Research Unit, Lyon, France
- Lyon Est Medical School, Université Claude Bernard, Lyon 1, Lyon, France
| | - Claus Peter Schmitt
- Center for Pediatric and Adolescent Medicine, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Sevcan A. Bakkaloglu
- Department of Pediatric Nephrology, School of Medicine, Gazi University, Ankara, Turkey
| | - Shelley Cleghorn
- Renal Unit, UCL Great Ormond Street Hospital and Institute of Child Health, London, UK
| | - Maren Leifheit-Nestler
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Pediatric Research Center, Hannover, Germany
| | - Agnieszka Prytula
- Department of Pediatric Nephrology and Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - Bruno Ranchin
- Reference Center for Rare Renal Diseases, Reference Center for Rare Diseases of Calcium and Phosphate Metabolism, Pediatric Nephrology Rheumatology and Dermatology Unit, Hopital Femme Mère Enfant, Boulevard Pinel, 69677 Bron, France
| | - Anne Schön
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Pediatric Research Center, Hannover, Germany
| | - Stella Stabouli
- 1st Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University Thessaloniki, Hippokratio Hospital, Thessaloniki, Greece
| | - Johan Van de Walle
- Department of Pediatric Nephrology and Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - Enrico Vidal
- Pediatric Nephrology Unit, University-Hospital of Padova, Padua, Italy
- Department of Medicine (DAME), University of Udine, Udine, Italy
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Pediatric Research Center, Hannover, Germany
| | - Rukshana Shroff
- Renal Unit, UCL Great Ormond Street Hospital and Institute of Child Health, London, UK
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Shen Y. Role of nutritional vitamin D in chronic kidney disease-mineral and bone disorder: A narrative review. Medicine (Baltimore) 2023; 102:e33477. [PMID: 37026958 PMCID: PMC10082266 DOI: 10.1097/md.0000000000033477] [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: 02/01/2023] [Accepted: 03/17/2023] [Indexed: 04/08/2023] Open
Abstract
Chronic kidney disease-mineral and bone disorder has complex and diverse clinical manifestations, including the simplest abnormalities of calcium, phosphorus and parathyroid hormone detected in blood, abnormalities of bone transformation and mineralization in bone, and calcification of blood vessels or other soft tissues detected on imaging. Patients with CKD-MBD combined low bone mineral density and fragility fractures are referred to as CKD-MBD with low bone mineral density. Vascular calcification refers to ectopic deposition of calcium phosphate in the blood vessel walls and heart valves. The degree of vascular calcification was inversely proportional to bone mineral density. The more severe the degree of vascular calcification, the lower the bone mineral density, and the higher the risk of death, indicating that the bone-vascular axis exists. Activation and alteration of the Wnt signaling pathway are central to the treatment of vascular diseases in uremia. Vitamin D supplementation can prevent secondary hyperparathyroidism, activate osteoblasts, relieve muscle weakness and myalgia, and reduce vascular calcification. Nutritional vitamin D may improve vascular calcification in uremia patients by regulating Wnt signaling pathway.
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Affiliation(s)
- Yingjing Shen
- Department of Nephrology, Shanghai Tianyou Hospital, Shanghai, China
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Levy RV, McMahon DJ, Agarwal S, Dempster D, Zhou H, Misof BM, Guo X, Kamanda-Kosseh M, Aponte MA, Reidy K, Kumar J, Fusaro M, Brown DD, Melamed ML, Nickolas TL. Comprehensive Associations between Acidosis and the Skeleton in Patients with Kidney Disease. J Am Soc Nephrol 2023; 34:668-681. [PMID: 36749125 PMCID: PMC10103353 DOI: 10.1681/asn.0000000000000085] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 01/10/2023] [Indexed: 02/08/2023] Open
Abstract
SIGNIFICANCE STATEMENT Renal osteodystrophy (ROD) contributes substantially to morbidity in CKD, including increased fracture risk. Metabolic acidosis (MA) contributes to the development of ROD, but an up-to-date skeletal phenotype in CKD-associated acidosis has not been described. We comprehensively studied associations between acidosis and bone in patients with CKD using advanced methods to image the skeleton and analyze bone-tissue, along with biochemical testing. Cross-sectionally, acidosis was associated with higher markers of bone remodeling and female-specific impairments in cortical and trabecular bone quality. Prospectively, acidosis was associated with cortical expansion and trabecular microarchitectural deterioration. At the bone-tissue level, acidosis was associated with deficits in bone mineral content. Future work investigating acidosis correction on bone quality is warranted. BACKGROUND Renal osteodystrophy is a state of impaired bone quality and strength. Metabolic acidosis (MA) is associated with alterations in bone quality including remodeling, microarchitecture, and mineralization. No studies in patients with CKD have provided a comprehensive multimodal skeletal phenotype of MA. We aim to describe the structure and makeup of bone in patients with MA in the setting of CKD using biochemistry, noninvasive imaging, and histomorphometry. METHODS The retrospective cross-sectional analyses included 180 patients with CKD. MA was defined as bicarbonate ≤22 mEq/L. We evaluated circulating bone turnover markers and skeletal imaging with dual energy x-ray absorptiometry and high-resolution peripheral computed tomography. A subset of 54 participants had follow-up. We assessed associations between baseline and change in bicarbonate with change in bone outcomes. Histomorphometry, microCT, and quantitative backscatter electron microscopy assessed bone biopsy outcomes in 22 participants. RESULTS The mean age was 68±10 years, 54% of participants were male, and 55% were White. At baseline, acidotic subjects had higher markers of bone turnover, lower areal bone mineral density at the radius by dual energy x-ray absorptiometry, and lower cortical and trabecular volumetric bone mineral density and impaired trabecular microarchitecture. Over time, acidosis was associated with opposing cortical and trabecular effects: cortical expansion but trabecular deterioration. Bone-tissue analyses showed reduced tissue mineral density with increased heterogeneity of calcium distribution in acidotic participants. CONCLUSIONS MA is associated with multiple impairments in bone quality. Future work should examine whether correction of acidosis improves bone quality and strength in patients with CKD.
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Affiliation(s)
- Rebecca V. Levy
- Nephrology, Department of Medicine, University of Rochester Medical Center Rochester, New York, USA
- Pediatric Nephrology, Department of Pediatrics, University of Rochester Medical Center, Rochester, New York, USA
| | | | | | - David Dempster
- Columbia University Irving Medical Center, New York, USA
| | - Hua Zhou
- Columbia University Irving Medical Center, New York, USA
| | - Barbara M. Misof
- Ludwig Boltzmann Institute for Osteology at the Hanusch Hospital of OEGK and AUVA Trauma Centre Meidling, 1st Medical Department, Hanusch Hospital, Vienna, Austria
| | - X.E. Guo
- Columbia University Biomedical Engineering, New York, New York, USA
| | | | | | - Kimberly Reidy
- Nephrology, Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
| | - Juhi Kumar
- Nephrology, Department of Pediatrics, Weill-Cornell Medical Center, New York, New York
| | - Maria Fusaro
- National Research Council (CNR), Institute of Clinical Physiology (IFC), Pisa, Italy
- Department of Medicine, University of Padova, Padova, Padua, Italy
| | - Denver D. Brown
- Division of Nephrology, Children's National Hospital, Washington, DC
| | - Michal L. Melamed
- Nephrology, Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
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Carbonara CE, Roza NA, dos Reis LM, Carvalho AB, Jorgetti V, de Oliveira RB. Overview of renal osteodystrophy in Brazil: a cross-sectional study. J Bras Nefrol 2023; 45:257-261. [PMID: 37158484 PMCID: PMC10627135 DOI: 10.1590/2175-8239-jbn-2022-0146en] [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] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 03/02/2023] [Indexed: 05/10/2023] Open
Abstract
INTRODUCTION The epidemiologic profile of renal osteodystrophy (ROD) is changing over time and cross-sectional studies provide essential information to improve care and health policies. The Brazilian Registry of Bone Biopsy (REBRABO) is a prospective, nationalmulticenter cohort that includes patients with chronic kidney disease (CKD) undergoing bone biopsy. REBRABO aims to provide clinical information on ROD. The main objective of this subanalysis was to describe the profile of ROD, including clinically relevant associations. METHODS From Aug/2015 to Dec/2021, 511 patients with CKD who performed bone biopsy were included in the REBRABO platform. Patients with no bone biopsy report (N = 40), GFR > 90 mL/min (N = 28), without asigned consent (N = 24), bone fragments inadequate for diagnosis (N = 23), bone biopsy indicated by a specialty other than nephrology (N = 6), and < 18 years old (N = 4) were excluded. Clinical-demographic data (e.g., age, sex, ethnicity, CKD etiology, dialysis vintage, comorbidities, symptoms, and complications related to ROD), laboratory (e.g., serum levels of total calcium, phosphate, parathormone, alkaline phosphatase, 25-hydroxyvitamin D, and hemoglobin), and ROD (e.g., histological diagnosis) were analyzed. RESULTS Data from 386 individuals were considered in this subanalysis of REBRABO. Mean age was 52 (42-60) years; 198 (51%) were male; 315 (82%) were on hemodialysis. Osteitis fibrosa (OF) [163 (42%)], adynamic bone disease (ABD) [96 (25%)] and mixed uremic osteodystrophy (MUO) [83 (21%)] were the most frequent diagnosis of ROD in our sample; 203 (54%) had the diagnosis of osteoporosis, 82 (56%) vascular calcification; 138 (36%) bone aluminum accumulation, and 137 (36%) iron intoxication; patients with high turnover were prone to present a higher frequency of symptoms. CONCLUSIONS A high proportion of patients were diagnosed with OF and ABD, as well as osteoporosis, vascular calcification and clinical symptoms.
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Affiliation(s)
- Cinthia E.M. Carbonara
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas,
Divisão de Nefrologia, Campinas, SP, Brazil
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas da
Campinas, Laboratório para o Estudo do Metabolismo Mineral e Ósseo em Nefrologia,
Campinas, Campinas, SP, Brazil
| | - Noemi A.V. Roza
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas da
Campinas, Laboratório para o Estudo do Metabolismo Mineral e Ósseo em Nefrologia,
Campinas, Campinas, SP, Brazil
| | - Luciene M. dos Reis
- Universidade de São Paulo, Faculdade de Medicina, Departamento de
Medicina Interna, Laboratório de Fisiopatologia Renal, São Paulo, SP, Brazil
| | | | - Vanda Jorgetti
- Universidade de São Paulo, Faculdade de Medicina, Departamento de
Medicina Interna, Laboratório de Fisiopatologia Renal, São Paulo, SP, Brazil
| | - Rodrigo Bueno de Oliveira
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas,
Divisão de Nefrologia, Campinas, SP, Brazil
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas da
Campinas, Laboratório para o Estudo do Metabolismo Mineral e Ósseo em Nefrologia,
Campinas, Campinas, SP, Brazil
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Modest J, Sheth H, Gohh R, Aaron R. Osteomalacia and Renal Osteodystrophy. R I Med J (2013) 2022; 105:22-27. [PMID: 36173905] [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] [Indexed: 06/16/2023]
Abstract
Osteomalacia is defined by the undermineralization of newly formed bone due to a lack of available calcium, phosphorus, or vitamin D. Causative factors of osteomalacia include nutritional deficiency, diminished absorptive capabilities (often due to gastrointestinal disorders), and renal insufficiency. Renal osteodystrophy is a specific form of metabolic bone disease defined by the presence of osteomalacia and associated hyperparathyroidism secondary to a malfunction in, or absence of, renal parenchyma. This reduces the conversion of vitamin D to its active form, thus leading to a cascade of effects that negatively impact the stability of the skeleton. Osteomalacia occurs across a spectrum of severity and can produce severe consequences for specific populations, including patients with dietary, nutritional, and absorptive deficiencies. Renal osteodystrophy affects patients with chronic kidney disease, those undergoing dialysis, and renal transplant patients. Special considerations must be taken into account when assessing the bone health of patients fitting these criteria.
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Affiliation(s)
- Jacob Modest
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI
| | - Himesh Sheth
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI
| | - Reginald Gohh
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI
| | - Roy Aaron
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI
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15
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Biruete A, Metzger CE, Chen NX, Swallow EA, Vrabec C, Clinkenbeard EL, Stacy AJ, Srinivasan S, O'Neill K, Avin KG, Allen MR, Moe SM. Effects of ferric citrate and intravenous iron sucrose on markers of mineral, bone, and iron homeostasis in a rat model of CKD-MBD. Nephrol Dial Transplant 2022; 37:1857-1867. [PMID: 35482713 PMCID: PMC9494145 DOI: 10.1093/ndt/gfac162] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 04/26/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Anemia and chronic kidney disease-mineral and bone disorder (CKD-MBD) are common and begin early in CKD. Limited studies have concurrently compared the effects of ferric citrate (FC) versus intravenous (IV) iron on CKD-MBD and iron homeostasis in moderate CKD. METHODS We tested the effects of 10 weeks of 2% FC versus IV iron sucrose in rats with moderate CKD (Cy/+ male rat) and untreated normal (NL) littermates. Outcomes included a comprehensive assessment of CKD-MBD, iron homeostasis and oxidative stress. RESULTS CKD rats had azotemia, elevated phosphorus, parathyroid hormone and fibroblast growth factor-23 (FGF23). Compared with untreated CKD rats, treatment with FC led to lower plasma phosphorus, intact FGF23 and a trend (P = 0.07) toward lower C-terminal FGF23. FC and IV iron equally reduced aorta and heart calcifications to levels similar to NL animals. Compared with NL animals, CKD animals had higher bone turnover, lower trabecular volume and no difference in mineralization; these were unaffected by either iron treatment. Rats treated with IV iron had cortical and bone mechanical properties similar to NL animals. FC increased the transferrin saturation rate compared with untreated CKD and NL rats. Neither iron treatment increased oxidative stress above that of untreated CKD. CONCLUSIONS Oral FC improved phosphorus homeostasis, some iron-related parameters and the production and cleavage of FGF23. The intermittent effect of low-dose IV iron sucrose on cardiovascular calcification and bone should be further explored in moderate-advanced CKD.
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Affiliation(s)
- Annabel Biruete
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Nutrition and Dietetics, Indiana University-Purdue University Indianapolis, Indianapolis, IN, USA
| | - Corinne E Metzger
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Neal X Chen
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Elizabeth A Swallow
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Curtis Vrabec
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA
- College of Osteopathic Medicine, Marian University, Indianapolis, IN, USA
| | - Erica L Clinkenbeard
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Alexander J Stacy
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Shruthi Srinivasan
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kalisha O'Neill
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Keith G Avin
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Physical Therapy, Indiana University School of Health and Human Sciences, Indiana University, Indianapolis, IN, USA
| | - Matthew R Allen
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, IN, USA
- Roudebush Veterans Affairs Medical Center, Indianapolis, IN, IN, USA
| | - Sharon M Moe
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, IN, USA
- Roudebush Veterans Affairs Medical Center, Indianapolis, IN, IN, USA
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Ferreira AC, Mendes M, Silva C, Cotovio P, Aires I, Navarro D, Caeiro F, Ramos R, Salvador R, Correia B, Cabral G, Nolasco F, Ferreira A. Improvement of Mineral and Bone Disorders After Renal Transplantation. Transplantation 2022; 106:e251-e261. [PMID: 35266925 PMCID: PMC9038238 DOI: 10.1097/tp.0000000000004099] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/07/2022] [Accepted: 01/19/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Posttransplant mineral and bone diseases are causes of fractures, and their association with cardiovascular events is being studied. METHODS We analyzed the evolution of biochemical, histological, and imaging parameters pre- and 1 y post-renal transplantation in 69 patients and correlated mineral and bone findings with coronary calcifications. At inclusion and after 12 mo, clinical data and echocardiographic findings were recorded, and laboratory evaluations, radiography of the pelvis and hands, and bone biopsy were performed. Noncontrast cardiac computed tomography was performed during the second evaluation. RESULTS Serum levels of fibroblast growth factor 23 and sclerostin decreased in all patients, parathyroid hormone levels decreased in 89.8% of patients, bone alkaline phosphatase levels decreased in 68.1% of patients, and alpha-Klotho levels increased in 65.2% of patients. More than half of the patients presented with renal osteodystrophy at both biopsies, but histological findings improved: a significant transition from high to normal or low turnover and no significant differences in volume, mineralization defect, or cortical porosity at the 2 evaluations. Alpha-Klotho, sclerostin, and bone alkaline phosphatase shifts affect bone changes. Neither echocardiographic findings nor vascular calcification scores differed between the 2 points. Both the pretransplant period (dialysis vintage, sclerostin, and low bone volume at baseline) and the maintenance of abnormalities in the posttransplant period (high turnover posttransplant) were the most reliable predictors of the severity of the coronary calcification percentile. CONCLUSIONS Renal transplantation improved bone and mineral abnormalities. The pretransplant period determines the severity of calcification.
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Affiliation(s)
- Ana Carina Ferreira
- Nephrology Department, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
- Nova Medical School, Lisbon, Portugal
| | - Marco Mendes
- Nephrology Department, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Cecília Silva
- Nephrology Department, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Patrícia Cotovio
- Nephrology Department, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Inês Aires
- Nephrology Department, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
- Nova Medical School, Lisbon, Portugal
| | - David Navarro
- Nephrology Department, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Fernando Caeiro
- Nephrology Department, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Rúben Ramos
- Cardiology Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Rute Salvador
- CEDOC, Tissue Repair and Inflammation Lab, Lisbon, Portugal
| | - Bruna Correia
- CEDOC, Tissue Repair and Inflammation Lab, Lisbon, Portugal
| | | | - Fernando Nolasco
- Nephrology Department, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
- Nova Medical School, Lisbon, Portugal
| | - Aníbal Ferreira
- Nephrology Department, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
- Nova Medical School, Lisbon, Portugal
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Soohoo M, Obi Y, Rivara MB, Adams SV, Lau WL, Rhee CM, Kovesdy CP, Kalantar-Zadeh K, Arah OA, Mehrotra R, Streja E. Comparative Effectiveness of Dialysis Modality on Laboratory Parameters of Mineral Metabolism. Am J Nephrol 2022; 53:157-168. [PMID: 35226895 PMCID: PMC9116596 DOI: 10.1159/000521508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 12/07/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Chronic kidney disease-mineral and bone disorders (CKD-MBD) are prevalent in patients undergoing maintenance dialysis. Yet, there are limited and mixed evidence on the effects of different dialysis modalities involving longer treatment times or higher frequencies on CKD-MBD markers. METHODS This cohort study used data from 132,523 incident dialysis patients treated with any of the following modalities: conventional thrice-weekly in-center hemodialysis, nocturnal in-center hemodialysis (NICHD), home hemodialysis (HHD), or peritoneal dialysis (PD) from 2007 to 2011. We used marginal structural models fitted with inverse probability weights to adjust for fixed and time-varying confounding and informative censoring. We estimated the average effects of treatments with different dialysis modalities on time-varying serum concentrations of CKD-MBD markers: albumin-corrected calcium, phosphate, parathyroid hormone (PTH), and alkaline phosphatase (ALP) using pooled linear regression. RESULTS Most of the cohort were exclusively treated with conventional in-center hemodialysis, while few were ever treated with NICHD or HHD. At the baseline, PD patients had the lowest mean and median values of PTH, while NICHD patients had the highest median values. During follow-up, compared to hemodialysis patients, patients treated with NICHD had lower mean serum PTH (19.8 pg/mL [95% confidence interval: 2.8, 36.8] lower), whereas PD and HHD patients had higher mean PTH (39.7 pg/mL [31.6, 47.8] and 51.2 pg/mL [33.0, 69.3] higher, respectively). Compared to hemodialysis patients, phosphate levels were lower for patients treated with NICHD (0.44 mg/dL [0.37, 0.52] lower), PD (0.15 mg/dL [0.12, 0.19] lower), or HHD (0.33 mg/dL [0.27, 0.40] lower). There were no clinically meaningful associations between dialysis modalities and concentrations of calcium or ALP. CONCLUSION In incident dialysis patients, compared to treatment with conventional in-center hemodialysis, treatments with other dialysis modalities with longer treatment times or higher frequency were associated with different patterns of serum phosphate and PTH. Given the recent growth in the use of dialysis modalities other than hemodialysis, the associations between the treatment and the CKD-MBD markers warrant additional study.
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Affiliation(s)
- Melissa Soohoo
- Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine Medical Center, Orange, California, USA
- Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, California, USA
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, California, USA
| | - Yoshitsugu Obi
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Matthew B. Rivara
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Scott V. Adams
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Wei Ling Lau
- Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine Medical Center, Orange, California, USA
| | - Connie M. Rhee
- Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine Medical Center, Orange, California, USA
| | - Csaba P. Kovesdy
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine Medical Center, Orange, California, USA
- Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, California, USA
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, California, USA
| | - Onyebuchi A. Arah
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, California, USA
- Department of Statistics, College of Letters and Science, University of California, Los Angeles (UCLA), Los Angeles, California, USA
- Section for Epidemiology, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Rajnish Mehrotra
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Elani Streja
- Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine Medical Center, Orange, California, USA
- Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, California, USA
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Sharma S, Gupta A. Adynamic bone disease: Revisited. Nefrologia 2022; 42:8-14. [PMID: 36153902 DOI: 10.1016/j.nefroe.2022.03.005] [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] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 11/16/2020] [Indexed: 06/16/2023] Open
Abstract
The bone and mineral disorders form an integral part of the management of a chronic kidney disease (CKD) patient. Amongst various types of bone pathologies in chronic kidney disease-mineral bone disorder (CKD-MBD), the prevalence of adynamic bone disease (ABD) is increasing. The present review discusses the updated pathophysiology, risk factors, and management of this disorder.
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Affiliation(s)
- Sonia Sharma
- Pediatric Nephrology, Max Superspeciality Hospital, Shalimar Bagh, New Delhi, India
| | - Ankur Gupta
- Department of Medicine, Whakatane Hospital, Whakatane, New Zealand.
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Abstract
After kidney transplantation, mineral and bone disorders are associated with higher risk of fractures and consequent morbidity and mortality. Disorders of calcium and phosphorus, vitamin D deficiency, and hyperparathyroidism are also common. The epidemiology of bone disease has evolved over the past several decades due to changes in immunosuppressive regimens, mainly glucocorticoid minimization or avoidance. The assessment of bone disease in kidney transplant recipients relies on risk factor recognition and bone mineral density assessment. Several drugs have been trialed for the treatment of post-transplant mineral and bone disorders. This review will focus on the epidemiology, effect, and treatment of metabolic and skeletal derangements in the transplant recipient.
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Affiliation(s)
- Pascale Khairallah
- Section of Nephrology and Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, Texas
| | - Thomas L. Nickolas
- Division of Nephrology, Columbia University Irving Medical Center, New York, New York
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20
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Evenepoel P, Cunningham J, Ferrari S, Haarhaus M, Javaid MK, Lafage-Proust MH, Prieto-Alhambra D, Torres PU, Cannata-Andia J. Diagnosis and management of osteoporosis in chronic kidney disease stages 4 to 5D: a call for a shift from nihilism to pragmatism. Osteoporos Int 2021; 32:2397-2405. [PMID: 34129059 DOI: 10.1007/s00198-021-05975-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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: 03/01/2021] [Accepted: 04/21/2021] [Indexed: 12/22/2022]
Abstract
The European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) CKD-MBD working group, in collaboration with the Committee of Scientific Advisors of the International Osteoporosis Foundation, published a position paper for the diagnosis and management of osteoporosis in patients with CKD stages 4-5D (eGFR < 30 ml/min 1.73 m2). The present article reports and summarizes the main recommendations included in this 2021 document. The following areas are reviewed: diagnosis of osteoporosis; risk factors for fragility fractures; fracture risk assessment; intervention thresholds for pharmacological intervention; general and pharmacological management of osteoporosis; monitoring of treatment, and systems of care, all in patients with CKD stages 4-5D. Guidance is provided for clinicians caring for CKD stages 4-5D patients with osteoporosis, allowing for a pragmatic individualized diagnostic and therapeutic approach as an alternative to current variations in care and treatment nihilism.
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Affiliation(s)
- P Evenepoel
- Division of Nephrology, University Hospitals Leuven, KU Leuven, Herestraat 49, B-3000, Leuven, Belgium.
| | - J Cunningham
- Centre for Nephrology, Royal Free Campus, UCL Medical School, Rowland Hill Street, London, NW3 2PF, UK
| | - S Ferrari
- Service of Bone diseases, Geneva university Hospital Switzerland, Rue Gabrielle-Perret-Gentil 4, 1205, Genève, Switzerland
| | - M Haarhaus
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet,, Karolinska University Hospital, Solna, Sweden
| | - M K Javaid
- NDORMS, University of Oxford, Windmill Road, Oxford, OX3 7HE, UK
| | | | - D Prieto-Alhambra
- CSM-NDORMS, University of Oxford, Windmill Road, Oxford, OX3 7LD, UK
| | - P U Torres
- AURA Nord Saint Ouen, 108 bis, avenue Gabriel Péri, 93400, Saint Ouen, France
- Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris, France
| | - J Cannata-Andia
- Bone and Mineral Research Unit (ISPA) (REDinREN), Hospital Universitario Central Asturias, Oviedo University, Asturias, Spain
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Abstract
PURPOSE OF REVIEW Chronic kidney disease-mineral and bone disorder (CKD-MBD) has become a global health crisis with very limited therapeutic options. Dentin matrix protein 1 (DMP1) is a matrix extracellular protein secreted by osteocytes that has generated recent interest for its possible involvement in CKD-MBD pathogenesis. This is a review of DMP1 established regulation and function, and early studies implicating DMP1 in CKD-MBD. RECENT FINDINGS Patients and mice with CKD show perturbations of DMP1 expression in bone, associated with impaired osteocyte maturation, mineralization, and increased fibroblast growth factor 23 (FGF23) production. In humans with CKD, low circulating DMP1 levels are independently associated with increased cardiovascular events. We recently showed that DMP1 supplementation lowers circulating FGF23 levels and improves bone mineralization and cardiac outcomes in mice with CKD. Mortality rates are extremely high among patients with CKD and have only marginally improved over decades. Bone disease and FGF23 excess contribute to mortality in CKD by increasing the risk of bone fractures and cardiovascular disease, respectively. Previous studies focused on DMP1 loss-of-function mutations have established its role in the regulation of FGF23 and bone mineralization. Recent studies show that DMP1 supplementation may fill a crucial therapeutic gap by improving bone and cardiac health in CKD.
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Affiliation(s)
- Aline Martin
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Feinberg Cardiovascular and Renal Research Institute, Northwestern University, Chicago, IL, 60611, USA.
| | - Dominik Kentrup
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Feinberg Cardiovascular and Renal Research Institute, Northwestern University, Chicago, IL, 60611, USA
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Liu L, Wang L, Li L, Wang H, Yuan L, Kang L, Jiang Q, Chen G, Lv N, Cui X, Huang L, Wu H, Xu J, Li Y. Effects of triangle grass decoction on bone metabolism in rats with chronic kidney disease complicated with mineral and bone abnormalities. J Ethnopharmacol 2021; 275:114126. [PMID: 33872749 DOI: 10.1016/j.jep.2021.114126] [Citation(s) in RCA: 3] [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] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 04/08/2021] [Accepted: 04/13/2021] [Indexed: 06/12/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Triangle grass is a liliaceous Chlorophytum perennial herb of ChlorophytumlaxumR.Br. It is distributed mainly in Guangdong and Guangxi Provinces of China. The initial use of triangle grass was mainly to treat bone pain and swelling caused by a fall injury. Triangle grass tablets (NO. Z20070544) are also used as a preparation in our hospital because of their analgesic, anti-inflammatory, anti-snake venom and microcirculation improvement properties and other pharmacological effects (Mei et al., 2006). Triangle grass tablets have been widely used in our hospital to treat patients with bone pain from chronic kidney disease-mineral and bone disorder (CKD-MBD). However, the effects and mechanism of triangle grass on bone metabolism in chronic kidney disease complicated with mineral and bone abnormalities are unclear. AIM OF THE STUDY The aim of the present study was to investigate the effects of a triangle grass decoction on bone metabolism in CKD-MBD rats. MATERIALS AND METHODS CKD-MBD model rats were subjected to 5/6 nephrectomy combined with 0.5 g NaH2PO4/rat. Serum blood urea nitrogen (BUN), creatinine (Cr), phosphorus (P), calcium (Ca), and intact parathyroid hormone (iPTH) levels were measured with an automatic biochemical analyser. Bone mineral density was determined with a Viva CT 40 system. Bone morphogenetic protein 7(BMP-7),runt-related transcription factor 2 (Runx2) and Osterix protein levels were measured by Western blot analysis. Kidney, vertebra and thoracic aorta tissue samples were assessed by histopathology and immunohistochemistry (IHC). RESULTS The degrees of membrane thickening, necrosis, swelling and cast deposition were significantly reduced in high-dose rats and Low-dose rats. Serum BUN levels were significantly reduced in the Pre-H group (P < 0.05). Hypocalcaemia and hyperphos phataemia were detected in triangle grass (P < 0.05, P < 0.05). In addition, iPTH levels were significantly increased in the Pre-H group (P < 0.05). Alkaline phosphatase (ALP)levels were significantly decreased in the Pre-H group (P < 0.05). The bone mineral density was improved in the Pre-H and Pre-L groups. BMP-7 protein levels were significantly increased in the Pre-H group (P < 0.05). The pathological changes in muscle fibres in the thoracic aorta middle membranes were significantly alleviated in rats in the Pre-H and Pre-L groups. Changes in SM22α and SMα-act in protein levels were significantly attenuated in the Pre-H group (P < 0.05, P < 0.05). Changes in Runx2 and Osterix protein levels were also significantly attenuated in the Pre-H and Pre-L groups (P < 0.05, P < 0.05). CONCLUSIONS Triangle grass can simultaneously ameliorate vertebral bone loss and abnormal calcification in the thoracic aorta. Triangle grass has a definite effect on bone metabolism disorder in CKD-MBD rats.
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Affiliation(s)
- Linna Liu
- Department of Nephrology, Zhongshan Hospital of Traditional Chinese Medicine, Zhongshan, 528400, China.
| | - Lei Wang
- Cardiovascular and Cerebrovascular Drugs Research and Development Center, Tianjin Institute of Medical and Pharmaceutical Sciences, Tianjin, 300020, China.
| | - Li Li
- Second Clinical College of Traditional Chinese Medicine, University of Guangzhou, Guangzhou, 510405, China.
| | - Hong Wang
- Cardiovascular and Cerebrovascular Drugs Research and Development Center, Tianjin Institute of Medical and Pharmaceutical Sciences, Tianjin, 300020, China.
| | - Ling Yuan
- Cardiovascular and Cerebrovascular Drugs Research and Development Center, Tianjin Institute of Medical and Pharmaceutical Sciences, Tianjin, 300020, China.
| | - Li Kang
- Cardiovascular and Cerebrovascular Drugs Research and Development Center, Tianjin Institute of Medical and Pharmaceutical Sciences, Tianjin, 300020, China.
| | - Qian Jiang
- Cardiovascular and Cerebrovascular Drugs Research and Development Center, Tianjin Institute of Medical and Pharmaceutical Sciences, Tianjin, 300020, China.
| | - Guan Chen
- Cardiovascular and Cerebrovascular Drugs Research and Development Center, Tianjin Institute of Medical and Pharmaceutical Sciences, Tianjin, 300020, China.
| | - Nan Lv
- Cardiovascular and Cerebrovascular Drugs Research and Development Center, Tianjin Institute of Medical and Pharmaceutical Sciences, Tianjin, 300020, China.
| | - Xiaoxue Cui
- Cardiovascular and Cerebrovascular Drugs Research and Development Center, Tianjin Institute of Medical and Pharmaceutical Sciences, Tianjin, 300020, China.
| | - Lin Huang
- Department of Nephrology, Zhongshan Hospital of Traditional Chinese Medicine, Zhongshan, 528400, China.
| | - Huifei Wu
- Department of Nephrology, Zhongshan Hospital of Traditional Chinese Medicine, Zhongshan, 528400, China.
| | - Juan Xu
- Department of Nephrology, Zhongshan Hospital of Traditional Chinese Medicine, Zhongshan, 528400, China.
| | - Yanlin Li
- Department of Nephrology, Zhongshan Hospital of Traditional Chinese Medicine, Zhongshan, 528400, China.
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Meza K, Biswas S, Zhu YS, Gajjar A, Perelstein E, Kumar J, Akchurin O. Tumor necrosis factor-alpha is associated with mineral bone disorder and growth impairment in children with chronic kidney disease. Pediatr Nephrol 2021; 36:1579-1587. [PMID: 33387018 PMCID: PMC8087625 DOI: 10.1007/s00467-020-04846-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 07/13/2020] [Revised: 09/09/2020] [Accepted: 10/27/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Mineral and bone disorder (MBD) and growth impairment are common complications of pediatric chronic kidney disease (CKD). Chronic inflammation detrimentally affects bone health and statural growth in non-CKD settings, but the impact of inflammation on CKD-MBD and growth in pediatric CKD remains poorly understood. This study assessed associations between inflammatory cytokines with biomarkers of CKD-MBD and statural growth in pediatric CKD. METHODS This is a cross-sectional study of children with predialysis CKD stages II-V. Cytokines (IL-1b, IL-4, IL-6, IL-8, IL-10, IL-12, IL-13, TNF-α, interferon-γ), bone alkaline phosphatase (BAP), and procollagen type 1 N-terminal propeptide (P1NP) were measured at the same time as standard CKD-MBD biomarkers. Associations between cytokines, CKD-MBD biomarkers, and height z-score were assessed using linear regression analysis. RESULTS Among 63 children, 52.4% had stage 3 CKD, 76.2% non-glomerular CKD etiology, and 21% short stature. TNF-α was the only cytokine associated with parathyroid hormone (PTH) independent of glomerular filtration rate. After stratification by low, medium, and high TNF-α tertiles, significant differences in PTH, serum phosphorus, alkaline phosphatase, BAP, P1NP, and height z-score were found. In a multivariate analysis, TNF-α positively associated with phosphorus, PTH, and alkaline phosphatase and inversely associated with height z-score, independent of kidney function, age, sex, and active vitamin D analogue use. CONCLUSIONS TNF-α is positively associated with biomarkers of CKD-MBD and inversely associated with height z-score, indicating that inflammation likely contributes to the development of CKD-MBD and growth impairment in pediatric CKD. Prospective studies to definitively assess causative effects of inflammation on bone health and growth in children with CKD are warranted.
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Affiliation(s)
- Kelly Meza
- Weill Cornell Medical College, Department of Pediatrics, New York, NY, USA
| | - Sharmi Biswas
- Weill Cornell Medical College, Department of Pediatrics, New York, NY, USA
| | - Yuan-Shan Zhu
- Weill Cornell Medical College, Department of Medicine, Clinical and Translational Science Center, New York, NY, USA
| | - Anuradha Gajjar
- Weill Cornell Medical College, Department of Pediatrics, New York, NY, USA
- Weill Cornell Medicine, New York-Presbyterian Phyllis and David Komansky Children's Hospital, 505 East 70th Street-HT 388, New York, NY, 10021, USA
| | - Eduardo Perelstein
- Weill Cornell Medical College, Department of Pediatrics, New York, NY, USA
- Weill Cornell Medicine, New York-Presbyterian Phyllis and David Komansky Children's Hospital, 505 East 70th Street-HT 388, New York, NY, 10021, USA
| | - Juhi Kumar
- Weill Cornell Medical College, Department of Pediatrics, New York, NY, USA
- Weill Cornell Medicine, New York-Presbyterian Phyllis and David Komansky Children's Hospital, 505 East 70th Street-HT 388, New York, NY, 10021, USA
| | - Oleh Akchurin
- Weill Cornell Medical College, Department of Pediatrics, New York, NY, USA.
- Weill Cornell Medicine, New York-Presbyterian Phyllis and David Komansky Children's Hospital, 505 East 70th Street-HT 388, New York, NY, 10021, USA.
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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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Hsu CY, Chen LR, Chen KH. Osteoporosis in Patients with Chronic Kidney Diseases: A Systemic Review. Int J Mol Sci 2020; 21:ijms21186846. [PMID: 32961953 PMCID: PMC7555655 DOI: 10.3390/ijms21186846] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 09/13/2020] [Accepted: 09/16/2020] [Indexed: 02/06/2023] Open
Abstract
Chronic kidney disease (CKD) is associated with the development of mineral bone disorder (MBD), osteoporosis, and fragility fractures. Among CKD patients, adynamic bone disease or low bone turnover is the most common type of renal osteodystrophy. The consequences of CKD-MBD include increased fracture risk, greater morbidity, and mortality. Thus, the goal is to prevent the occurrences of fractures by means of alleviating CKD-induced MBD and treating subsequent osteoporosis. Changes in mineral and humoral metabolism as well as bone structure develop early in the course of CKD. CKD-MBD includes abnormalities of calcium, phosphorus, PTH, and/or vitamin D; abnormalities in bone turnover, mineralization, volume, linear growth, or strength; and/or vascular or other soft tissue calcification. In patients with CKD-MBD, using either DXA or FRAX to screen fracture risk should be considered. Biomarkers such as bALP and iPTH may assist to assess bone turnover. Before initiating an antiresorptive or anabolic agent to treat osteoporosis in CKD patients, lifestyle modifications, such as exercise, calcium, and vitamin D supplementation, smoking cessation, and avoidance of excessive alcohol intake are important. Managing hyperphosphatemia and SHPT are also crucial. Understanding the complex pathogenesis of CKD-MBD is crucial in improving one’s short- and long-term outcomes. Treatment strategies for CKD-associated osteoporosis should be patient-centered to determine the type of renal osteodystrophy. This review focuses on the mechanism, evaluation and management of patients with CKD-MBD. However, further studies are needed to explore more details regarding the underlying pathophysiology and to assess the safety and efficacy of agents for treating CKD-MBD.
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Affiliation(s)
- Chia-Yu Hsu
- Department of Rehabilitation Medicine, Ten-Chan General Hospital, Zhongli, Taoyuan 320, Taiwan;
- Department of Biomedical Engineering, Chung Yuan Christian University, Taoyuan 320, Taiwan
| | - Li-Ru Chen
- Department of Physical Medicine and Rehabilitation, Mackay Memorial Hospital, Taipei 104, Taiwan;
- Department of Mechanical Engineering, National Chiao-Tung University, Hsinchu 300, Taiwan
| | - Kuo-Hu Chen
- Department of Obstetrics and Gynecology, Taipei Tzu-Chi Hospital, The Buddhist Tzu-Chi Medical Foundation, Taipei 231, Taiwan
- Department of Medicine, School of Medicine, Tzu-Chi University, Hualien 970, Taiwan
- Correspondence: ; Tel.: +886-2662-89779
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Ewert A, Leifheit-Nestler M, Hohenfellner K, Büscher A, Kemper MJ, Oh J, Billing H, Thumfart J, Stangl G, Baur AC, Föller M, Feger M, Weber LT, Acham-Roschitz B, Arbeiter K, Tönshoff B, Zivicnjak M, Haffner D. Bone and Mineral Metabolism in Children with Nephropathic Cystinosis Compared with other CKD Entities. J Clin Endocrinol Metab 2020; 105:5837710. [PMID: 32413117 DOI: 10.1210/clinem/dgaa267] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [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: 03/19/2020] [Accepted: 05/08/2020] [Indexed: 02/06/2023]
Abstract
CONTEXT Children with nephropathic cystinosis (NC) show persistent hypophosphatemia, due to Fanconi syndrome, as well as mineral and bone disorders related to chronic kidney disease (CKD); however, systematic analyses are lacking. OBJECTIVE To compare biochemical parameters of bone and mineral metabolism between children with NC and controls across all stages of CKD. DESIGN Cross-sectional multicenter study. SETTING Hospital clinics. PATIENTS Forty-nine children with NC, 80 CKD controls of the same age and CKD stage. MAIN OUTCOME MEASURES Fibroblast growth factor 23 (FGF23), soluble Klotho, bone alkaline phosphatase (BAP), tartrate-resistant acid phosphatase 5b (TRAP5b), sclerostin, osteoprotegerin (OPG), biochemical parameters related to mineral metabolism, and skeletal comorbidity. RESULTS Despite Fanconi syndrome medication, NC patients showed an 11-fold increased risk of short stature, bone deformities, and/or requirement for skeletal surgery compared with CKD controls. This was associated with a higher frequency of risk factors such as hypophosphatemia, hypocalcemia, low parathyroid hormone (PTH), metabolic acidosis, and a specific CKD stage-dependent pattern of bone marker alterations. Pretransplant NC patients in mild to moderate CKD showed a delayed increase or lacked an increase in FGF23 and sclerostin, and increased BAP, TRAP5b, and OPG concentrations compared with CKD controls. Post-transplant, BAP and OPG returned to normal, TRAP5b further increased, whereas FGF23 and PTH were less elevated compared with CKD controls and associated with higher serum phosphate. CONCLUSIONS Patients with NC show more severe skeletal comorbidity associated with distinct CKD stage-dependent alterations of bone metabolism than CKD controls, suggesting impaired mineralization and increased bone resorption, which is only partially normalized after renal transplantation.
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Affiliation(s)
- Annika Ewert
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School Children's Hospital, Hannover, Germany
| | - Maren Leifheit-Nestler
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School Children's Hospital, Hannover, Germany
| | | | - Anja Büscher
- Department of Pediatrics II, University Hospital Essen, Essen, Germany
| | | | - Jun Oh
- Division of Pediatric Nephrology, University Children's Hospital Hamburg, Hamburg, Germany
| | - Heiko Billing
- Division of Pediatric Nephrology, University Children's Hospital Tübingen, Tübingen, Germany
| | - Julia Thumfart
- Department of Pediatric Gastroenterology, Nephrology and Metabolism, Charite Hospital, Berlin, Germany
| | - Gabriele Stangl
- Institute of Agricultural and Nutritional Sciences, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Anja C Baur
- Institute of Agricultural and Nutritional Sciences, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Michael Föller
- Institute of Physiology, University of Hohenheim, Stuttgart, Germany
| | - Martina Feger
- Institute of Physiology, University of Hohenheim, Stuttgart, Germany
| | - Lutz T Weber
- Division of Pediatric Nephrology, Children´s and Adolescents´ Hospital, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | | | - Klaus Arbeiter
- Division of Pediatric Nephrology and Gastroenterology, Medical University Vienna, Austria
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Miroslav Zivicnjak
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School Children's Hospital, Hannover, Germany
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School Children's Hospital, Hannover, Germany
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Hunter PG, Miller-Hodges E, Hunter RW, Dhaun N. Forgotten signs of chronic kidney disease-associated mineral bone disease. QJM 2020; 113:359-360. [PMID: 31411332 PMCID: PMC7205453 DOI: 10.1093/qjmed/hcz211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- P G Hunter
- Department of Renal Medicine, Royal Infirmary of Edinburgh, 53 Little France Crescent, Edinburgh EH16 4SA, UK
| | - E Miller-Hodges
- Department of Renal Medicine, Royal Infirmary of Edinburgh, 53 Little France Crescent, Edinburgh EH16 4SA, UK
| | - R W Hunter
- Department of Renal Medicine, Royal Infirmary of Edinburgh, 53 Little France Crescent, Edinburgh EH16 4SA, UK
| | - N Dhaun
- Department of Renal Medicine, Royal Infirmary of Edinburgh, 53 Little France Crescent, Edinburgh EH16 4SA, UK
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Machuca-Gayet I, Quinaux T, Bertholet-Thomas A, Gaillard S, Claramunt-Taberner D, Acquaviva-Bourdain C, Bacchetta J. Bone Disease in Nephropathic Cystinosis: Beyond Renal Osteodystrophy. Int J Mol Sci 2020; 21:ijms21093109. [PMID: 32354056 PMCID: PMC7246679 DOI: 10.3390/ijms21093109] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/23/2020] [Accepted: 04/27/2020] [Indexed: 12/20/2022] Open
Abstract
Patients with chronic kidney disease (CKD) display significant mineral and bone disorders (CKD-MBD) that induce significant cardiovascular, growth and bone comorbidities. Nephropathic cystinosis is an inherited metabolic disorder caused by the lysosomal accumulation of cystine due to mutations in the CTNS gene encoding cystinosin, and leads to end-stage renal disease within the second decade. The cornerstone of management relies on cysteamine therapy to decrease lysosomal cystine accumulation in target organs. However, despite cysteamine therapy, patients display severe bone symptoms, and the concept of “cystinosis metabolic bone disease” is currently emerging. Even though its exact pathophysiology remains unclear, at least five distinct but complementary entities can explain bone impairment in addition to CKD-MBD: long-term consequences of renal Fanconi syndrome, malnutrition and copper deficiency, hormonal disturbances, myopathy, and intrinsic/iatrogenic bone defects. Direct effects of both CTNS mutation and cysteamine on osteoblasts and osteoclasts are described. Thus, the main objective of this manuscript is not only to provide a clinical update on bone disease in cystinosis, but also to summarize the current experimental evidence demonstrating a functional impairment of bone cells in this disease and to discuss new working hypotheses that deserve future research in the field.
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Affiliation(s)
- Irma Machuca-Gayet
- Pathophysiology, Diagnosis and Treatment of Bone Diseases, INSERM UMR 1033, 69008 Lyon, France; (I.M.-G.); (T.Q.); (D.C.-T.)
| | - Thomas Quinaux
- Pathophysiology, Diagnosis and Treatment of Bone Diseases, INSERM UMR 1033, 69008 Lyon, France; (I.M.-G.); (T.Q.); (D.C.-T.)
- Centre de Référence des Maladies Rénales Rares, Centre de Référence des Maladies Rares du Calcium et du Phosphore, Hôpital Femme Mère Enfant, 69500 Bron, France;
| | - Aurélia Bertholet-Thomas
- Centre de Référence des Maladies Rénales Rares, Centre de Référence des Maladies Rares du Calcium et du Phosphore, Hôpital Femme Mère Enfant, 69500 Bron, France;
| | - Ségolène Gaillard
- INSERM CIC 1407, CNRS UMR 5558 and Service de Pharmacotoxicologie Clinique, Hospices Civils de Lyon, 69500 Bron, France;
| | - Débora Claramunt-Taberner
- Pathophysiology, Diagnosis and Treatment of Bone Diseases, INSERM UMR 1033, 69008 Lyon, France; (I.M.-G.); (T.Q.); (D.C.-T.)
| | | | - Justine Bacchetta
- Pathophysiology, Diagnosis and Treatment of Bone Diseases, INSERM UMR 1033, 69008 Lyon, France; (I.M.-G.); (T.Q.); (D.C.-T.)
- Centre de Référence des Maladies Rénales Rares, Centre de Référence des Maladies Rares du Calcium et du Phosphore, Hôpital Femme Mère Enfant, 69500 Bron, France;
- Faculté de Médecine Lyon Est, Université de Lyon, 69008 Lyon, France
- Correspondence: ; Tel.: +33-4-27-85-61-30
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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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Biruete A, Srinivasan S, O'Neill KD, Vorland CJ, Hill Gallant KM, Cai W, Uribarri J, Johnston N, Allen MR, Chen NX, Moe SM. Adverse Effects of Autoclaved Diets on the Progression of Chronic Kidney Disease and Chronic Kidney Disease-Mineral Bone Disorder in Rats. Am J Nephrol 2020; 51:381-389. [PMID: 32146472 PMCID: PMC7228841 DOI: 10.1159/000506729] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 02/20/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND Autoclaving rodent diets is common in laboratory animals, but autoclaving increases the formation of dietary advanced glycation end-products (AGE). We studied the effect of autoclaved (AC) diet alone or in combination with a diet high in bioavailable phosphorus on biochemistries of chronic kidney disease-mineral and bone disorder (CKD-MBD), intestinal gene expression, and oxidative stress. METHODS Male CKD rats (Cy/+) and normal littermates were fed 1 of 3 diets: AC 0.7% phosphorus grain-based diet for 28 weeks (AC); AC diet for 17 weeks followed by non-autoclaved (Non-AC) 0.7% phosphorus casein diet until 28 weeks (AC + Casein); or Non-AC diet for 16 weeks followed by a Non-AC purified diet until 30 weeks (Non-AC + Casein). RESULTS AC diets contained ~3× higher AGEs and levels varied depending on the location within the autoclave. Rats fed the AC and AC + Casein diets had higher total AGEs and oxidative stress, irrespective of kidney function. Kidney function was more severely compromised in CKD rats fed AC or AC + Casein compared to Non-AC + Casein. There was a disease-by-diet interaction for plasma phosphorus, parathyroid hormone, and c-terminal fibroblast growth factor-23, driven by high values in the CKD rats fed the AC + Casein diet. Compared to Non-AC + Casein, AC and AC + Casein-fed groups had increased expression of receptor of AGEs and intestinal NADPH oxidase dual oxidase-2, independent of kidney function. CONCLUSIONS Autoclaving rodent diets impacts the progression of CKD and CKD-MBD, highlighting the critical importance of standardizing diets in experiments.
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Affiliation(s)
- Annabel Biruete
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Department of Anatomy and Cell Biology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Shruthi Srinivasan
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kalisha D O'Neill
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Colby J Vorland
- Department of Applied Health Science, School of Public Health-Bloomington, Indiana University, Bloomington, Indiana, USA
- Department of Nutrition Science, Purdue University, West Lafayette, Indiana, USA
| | - Kathleen M Hill Gallant
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Department of Nutrition Science, Purdue University, West Lafayette, Indiana, USA
| | - Weijing Cai
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jaime Uribarri
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nancy Johnston
- Laboratory Animal Resource Center, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Matthew R Allen
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Department of Anatomy and Cell Biology, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana, USA
| | - Neal X Chen
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Sharon M Moe
- Division of Nephrology, Indiana University School of Medicine, Indianapolis, Indiana, USA,
- Department of Anatomy and Cell Biology, Indiana University School of Medicine, Indianapolis, Indiana, USA,
- Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana, USA,
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Sessa C, Galeano D, Alessandrello I, Aprile G, Distefano G, Ficara V, Giglio E, Musumeci S, Pocorobba B, Zuppardo C, Musso S, Granata A. [Osteoporosis and chronic kidney disease: review and new therapeutic strategies]. G Ital Nefrol 2019; 36:36-4-2019-4. [PMID: 31373465] [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] [Indexed: 06/10/2023]
Abstract
Osteoporosis affects a segment of the population in which Chronic Kidney Disease is also greatly represented. Nephropathic patients may present peculiar biochemical abnormalities related to Chronic Kidney Disease, defining the Mineral and Bone Disorder. This kind of anomalies, in the worst scenarios, configure the typical histomorphology patterns of Renal Osteodystrophy. Scientific Societies of Endocrinology have established therapy guidelines for patients with osteoporosis only based on the glomerular filtration rate and recommend avoiding the use of some drugs for the more advanced classes of nephropathy. However, there is no clear therapeutic approach for patients with advanced nephropathy and bone abnormalities. In this paper we propose a systematic review of the literature and present our proposal for managing patients with advanced nephropathy, based on eGFR and on presence of Mineral and Bone Disorder.
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Affiliation(s)
- Concetto Sessa
- U.O.C Nefrologia e Dialisi, P.O. "Maggiore" di Modica. Azienda Sanitaria Provinciale di Ragusa, Ragusa
| | - Dario Galeano
- U.O.C Nefrologia e Dialisi, P.O. "Maggiore" di Modica. Azienda Sanitaria Provinciale di Ragusa, Ragusa
| | - Ivana Alessandrello
- U.O.C Nefrologia e Dialisi, P.O. "Maggiore" di Modica. Azienda Sanitaria Provinciale di Ragusa, Ragusa
| | - Giorgio Aprile
- U.O.C Nefrologia e Dialisi, P.O. "Maggiore" di Modica. Azienda Sanitaria Provinciale di Ragusa, Ragusa
| | - Giulio Distefano
- U.O. Radiologia I, Dipartimento di Scienze Mediche, Chirurgiche e Tecnologie Avanzate "G.F. Ingrassia", Università di Catania, Catania
| | - Vincenzo Ficara
- U.O.C Nefrologia e Dialisi, P.O. "Maggiore" di Modica. Azienda Sanitaria Provinciale di Ragusa, Ragusa
| | - Elisa Giglio
- U.O.C Nefrologia e Dialisi, P.O. "Maggiore" di Modica. Azienda Sanitaria Provinciale di Ragusa, Ragusa
| | - Stella Musumeci
- U.O.C Nefrologia e Dialisi, P.O. "Maggiore" di Modica. Azienda Sanitaria Provinciale di Ragusa, Ragusa
| | - Barbara Pocorobba
- U.O.C Nefrologia e Dialisi, P.O. "Maggiore" di Modica. Azienda Sanitaria Provinciale di Ragusa, Ragusa
| | - Carmelo Zuppardo
- U.O.C Nefrologia e Dialisi, P.O. "Maggiore" di Modica. Azienda Sanitaria Provinciale di Ragusa, Ragusa
| | - Salvatore Musso
- U.O.C Nefrologia e Dialisi, P.O. "Maggiore" di Modica. Azienda Sanitaria Provinciale di Ragusa, Ragusa
| | - Antonio Granata
- U.O.C. Nefrologia e Dialisi - P.O. "San Giovanni di Dio", Agrigento - Italia
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Pereira RC, Salusky IB, Roschger P, Klaushofer K, Yadin O, Freymiller EG, Bowen R, Delany AM, Fratzl-Zelman N, Wesseling-Perry K. Impaired osteocyte maturation in the pathogenesis of renal osteodystrophy. Kidney Int 2019; 94:1002-1012. [PMID: 30348285 DOI: 10.1016/j.kint.2018.08.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [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: 04/13/2018] [Revised: 07/18/2018] [Accepted: 08/09/2018] [Indexed: 12/18/2022]
Abstract
Pediatric renal osteodystrophy is characterized by skeletal mineralization defects, but the role of osteoblast and osteocyte maturation in the pathogenesis of these defects is unknown. We evaluated markers of osteocyte maturation and programmed cell death in iliac crest biopsy samples from pediatric dialysis patients and healthy controls. We evaluated the relationship between numbers of fibroblast growth factor 23 (FGF23)-expressing osteocytes and histomorphometric parameters of skeletal mineralization. We confirmed that chronic kidney disease (CKD) causes intrinsic changes in bone cell maturation using an in vitro model of primary osteoblasts from patients with CKD and healthy controls. FGF23 co-localized with the early osteocyte marker E11/gp38, suggesting that FGF23 is a marker of early osteocyte maturation. Increased numbers of early osteocytes and decreased osteocyte apoptosis characterized CKD bone. Numbers of FGF23-expressing osteocytes were highest in patients with preserved skeletal mineralization indices, and packets of matrix surrounding FGF23-expressing osteocytes appeared to have entered secondary mineralization. Primary osteoblasts from patients with CKD retained impaired maturation and mineralization characteristics in vitro. Addition of FGF23 did not affect primary osteoblast mineralization. Thus, CKD is associated with intrinsic changes in osteoblast and osteocyte maturation, and FGF23 appears to mark a relatively early stage in osteocyte maturation. Improved control of renal osteodystrophy and FGF23 excess will require further investigation into the pathogenesis of CKD-mediated osteoblast and osteocyte maturation failure.
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Affiliation(s)
- Renata C Pereira
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Isidro B Salusky
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Paul Roschger
- Ludwig Boltzmann Institute of Osteology at the Hanusch Hospital of WGK and AUVA Trauma Centre Meidling, 1(st) Medical Department, Hanusch Hospital, Vienna, Austria
| | - Klaus Klaushofer
- Ludwig Boltzmann Institute of Osteology at the Hanusch Hospital of WGK and AUVA Trauma Centre Meidling, 1(st) Medical Department, Hanusch Hospital, Vienna, Austria
| | - Ora Yadin
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | | | - Richard Bowen
- Department of Orthopedics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Anne M Delany
- Center for Molecular Oncology, UConn Health, Farmington, Connecticut, USA
| | - Nadja Fratzl-Zelman
- Ludwig Boltzmann Institute of Osteology at the Hanusch Hospital of WGK and AUVA Trauma Centre Meidling, 1(st) Medical Department, Hanusch Hospital, Vienna, Austria
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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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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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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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37
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Abstract
PURPOSE OF REVIEW Although we have seen tremendous advances in the comprehension of CKD-MBD pathophysiology during the last few years, this was not accompanied by a significant change in mortality rate and quality of life. This review will address the traditional and updated pathophysiology of CKD-MBD along with the therapeutic limitations that affect CKD-MBD and proposed alternative treatment targets. RECENT FINDINGS An innovative concept brings the osteocyte to the center of CKD-MBD pathophysiology, in contrast to the traditional view of the skeleton as a target organ for disturbances in calcium, phosphate, parathyroid hormone, and vitamin D. Osteocytes, through the synthesis of FGF-23, sclerostin, among others, are able to interact with other organs, making bone an endocrine organ. Thus, osteocyte dysregulation might be an early event during the course of CKD. This review will revisit general concepts on the pathophysiology of CKD-MBD and discuss new perspectives for its treatment.
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Affiliation(s)
- Rosilene Motta Elias
- Universidade Nove de Julho, UNINOVE, Rua Iperoig, 690 ap 121, São Paulo, SP, 05016-000, Brazil
- Nephrology Division, HCFCMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Maria Aparecida Dalboni
- Universidade Nove de Julho, UNINOVE, Rua Iperoig, 690 ap 121, São Paulo, SP, 05016-000, Brazil
| | | | - Rosa M A Moysés
- Universidade Nove de Julho, UNINOVE, Rua Iperoig, 690 ap 121, São Paulo, SP, 05016-000, Brazil.
- Nephrology Division, HCFCMUSP, Universidade de São Paulo, São Paulo, Brazil.
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38
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Abstract
Ensuring patient safety is a priority of medical care because iatrogenic injury has been a primary concern. Medications are an important source of medical errors, and kidney disease is a thoroughfare of factors threatening safe administration of medicines. Principal among these is reduced kidney function because almost half of all medications used are eliminated via the kidney. Additionally, kidney patients often suffer from multimorbidity, including diabetes, hypertension, and heart failure, with a range of prescribers who often do not coordinate treatments. Patients with kidney disease are also susceptible to further kidney injury and metabolic derangements from medications, which can worsen the disease. In this review, we will present the key issues and threats to safe medication use in kidney disease, with a focus on predialysis CKD, as the scope of medication safety in ESKD and transplantation are unique and deserve their own consideration. We discuss drugs that need to be avoided or dose modified, and review the complications of a range of medications routinely administered in CKD, as these also call for cautious use.
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Affiliation(s)
- Chanel F. Whittaker
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Margaret A. Miklich
- Department of Pharmacy Practice, Temple University School of Pharmacy, Philadelphia, Pennsylvania
| | - Roshni S. Patel
- Department of Pharmacy Practice, Jefferson College of Pharmacy, Philadelphia, Pennsylvania; and
| | - Jeffrey C. Fink
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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39
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Andrade GS, de Souza Carvalho ACG, Magalhães TG, Cetira Filho EL, Cavalcante RB, Nogueira RLM. Expansive renal osteitis fibrosa: a case report. Oral Maxillofac Surg 2018; 22:323-327. [PMID: 29725779 DOI: 10.1007/s10006-018-0697-7] [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: 11/02/2017] [Accepted: 04/26/2018] [Indexed: 06/08/2023]
Abstract
Hyperparathyroidism (HPT) is an endocrine metabolic disorder characterized by increased secretion of parathyroid hormone. Untreated secondary HPT leads to renal osteodystrophy (ROD). Facial skeletal abnormalities in patients with ROD are rare. The purpose of this paper is to report a conservative surgical approach of exuberant osteitis fibrosa lesions in patient with chronic kidney disease. A 24-year-old female was referred to maxillofacial surgery department with giants ROD affecting palate, maxilla, and mandible, resulting in esthetic and functional impairment. The pathogeneses and multidisciplinary management of ROD are discussed with a brief literature review. Eight years after the conservative treatment of exuberant jaw lesions, no noticeable bone changes were observed in the patient. A multidisciplinary therapy is essential for correct diagnosis of ROD and optimal multimodality treatment. The conservative management was an efficient alternative for the success of the case reported.
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Affiliation(s)
| | | | | | - Edson Luiz Cetira Filho
- Division of Oral and Maxillofacial Surgery, IJF Hospital - Institute Dr. José Frota, Barão do Rio Branco street, 1816 - Center, Fortaleza, Ceará, 60025-061, Brazil.
| | - Roberta Barroso Cavalcante
- Department of Oral and Maxillofacial Pathology, Fortaleza University School of Dentistry, Fortaleza, Brazil
| | - Renato Luiz Maia Nogueira
- Department of Oral Surgery, Discipline of Oral and Maxillofacial Surgery and Stomatology, Federal University of Ceará School of Dentistry, Fortaleza, Ceará, Brazil
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40
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Abstract
BACKROUND Secondary hyperparathyroidism (SHPT) is a manifestation of chronic kidney disease mineral bone disorder (CKD-MBD). SHPT is common in patients with chronic kidney disease (CKD) and is associated with significant morbidity and mortality. METHODS A cross- sectional descriptive study involving 230 patients with CKD. RESULTS The mean age of the study population was 44.17±15.24 years. The median intact parathyroid hormone and alkaline phosphatase levels were 96pg/ml (range 4-953pg/ml) and 88 iu/l (range 10-800 iu/l) respectively. The mean (with standard deviation) calcium, serum phosphate, calcium phosphate product and haemoglobin levels were 2.22±0.29mmol/l, 1.8±0.62mmol/l, 3.94±1.42mmol2/l2 and 9.90±1.87g/dl respectively. Majority of patients had advanced CKD with 70.3% of patients in stage G5. The prevalence rates of SHPT, hypocalcaemia, hyperphosphataemia, elevated alkaline phosphatase and elevated calcium phosphate product were 55.2%, 34.8%, 66.1%, 42.2% and 25.2% respectively.Univariate analysis revealed that SHPT was associated with hypocalcaemia, hyperphosphataemia, elevated alkaline phosphatase, proteinuria, anaemia, hypertension, left ventricular hypertrophy and stage of kidney disease; being worse with advancing kidney disease. Independently associated with SHPT were hypocalcaemia (OR=4.84), hyperphosphataemia (OR=3.06), and elevated alkaline phosphatase (OR=2.04). CONCLUSION The prevalence of SHPT in CKD is high, occurs early and is independently associated with hypocalcaemia, hyperphosphataemia and elevated alkaline phosphatase. The prevalence of SHPT also increases with worsening renal function.
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Affiliation(s)
- Zumnan M Gimba
- Nephrology Division, Department of Medicine, Jos University Teaching Hospital, Nigeria
| | - Esala E Abene
- Nephrology Division, Department of Medicine, Jos University Teaching Hospital, Nigeria
| | - Oche O O Agbaji
- Nephrology Division, Department of Medicine, Jos University Teaching Hospital, Nigeria
- Department of Medicine, University of Jos
| | - Emmanuel I Agaba
- Nephrology Division, Department of Medicine, Jos University Teaching Hospital, Nigeria
- Department of Medicine, University of Jos
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41
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Rocca AR, Gnerre Musto T, Mazzaferro S. [CKD-MBD in Peritoneal Dialysis]. G Ital Nefrol 2018; 35:2018-vol2-4. [PMID: 29582958] [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] [Indexed: 06/08/2023]
Abstract
CKD-MBD is a systemic disorder of the mineral and bone metabolism as a result of CKD. The clinical relevance of this syndrome has led to the identification of the biochemical targets to be achieved in order to improve the outcome of the patient. However, in hemodialysis (HD) and peritoneal dialysis (DP) patients, these targets are not reached. Hyperphosphatemia is a predictor of cardiovascular and all-cause mortality. In DP the removal of phosphorus (P) occurs by diffusion and convection, with a contribution of ultrafiltration of about 11%. P clearance is time dependent, with differences between CAPD and APD and depending on membrane transport characteristics. Residual renal function plays a key role in the P balance. Calcium (Ca) clearance in PD depends on the calcium levels, calcium concentration in dialysate and ultrafiltration. Positive Ca balance brings to Adynamic Bone Disease. Several bone-derived substances, some of them with hormonal action, have shed new light on the bone- cardiac axis. The hormonal functions of bone are likely to be related to histological lesions that develop during chronic renal failure. Compared to the past, recent data show less obvious differences in bone histomorphometry parameters between HD patients and PD patients. However, in PD patients fewer fractures are reported, probably due to different bone quality.
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Affiliation(s)
- Anna Rachele Rocca
- Dipartimento di Scienze Cardiovascolari Respiratorie Nefrologiche Anestetiche e Geriatriche. Sapienza Università di Roma
| | - Tania Gnerre Musto
- Dipartimento di Scienze Cardiovascolari Respiratorie Nefrologiche Anestetiche e Geriatriche. Sapienza Università di Roma
| | - Sandro Mazzaferro
- Dipartimento di Scienze Cardiovascolari Respiratorie Nefrologiche Anestetiche e Geriatriche. Sapienza Università di Roma
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42
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Fusaro M, Aghi A, Mereu MC, Giusti A. [Fragility fracture in the Chronic Kidney Disease (CKD)]. G Ital Nefrol 2017; 34:2017-vol6-7. [PMID: 29207223] [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] [Indexed: 06/07/2023]
Abstract
Fragility fractures (FF) are common in patients with chronic kidney disease (CKD), and they occur at a younger age and with a higher frequency than in the general population, producing significant morbidity, mortality and healthcare costs. The pathogenic mechanisms underlying FF in CKD patients have not been completely understood. Behind CKD-MBD, the uremic toxicity should play a role in their pathogenesis, by affecting bone quality (uremic osteoporosis). There are very few prospective studies investigating risk factors for fragility fractures in CKD patients, and available algorithms for fracture risk prediction (FRAX and DeFRA) have never considered CKD. The diagnosis of vertebral fractures (FV), under-diagnosed in CKD patients as well as in general population, should be performed by Quantitative Vertebral Morphometry (QVM) both with DXA or Spine (D4-L5) x-Ray. A recent KDIGO review has qualified the measurement of the Bone Mineral Density by DXA as a predictive tool for fracture risk assessment in patients with stage G3a-G5D. Furthermore, the Trabecular Bone Score (TBS, software applied to DXA) allows the bone quality evaluation as well as the fracture risk prediction. Other techniques, such as Quantitative Computerized Tomography (QCT), especially High Resolution-peripheral QCT (HR-pQCT), have been shown to be useful, although expensive. Finally, some bone biomarkers (PTH and BAP) demonstrated to be informative for the definition of fracture risk in patients with CKD-MBD. In conclusion, there are several different tools and approaches that demonstrated to be useful for the identification of CKD patients at high risk of fracture, when these are appropriately performed and interpreted by expertise clinicians.
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Affiliation(s)
- Maria Fusaro
- Consiglio Nazionale delle Ricerche (CNR) - Istituto di Fisiologia Clinica (IFC), Pisa e Dipartimento di Medicina, Università di Padova
- Dipartimento di Medicina, Università degli Studi di Padova
| | - Andrea Aghi
- Clinica Medica 1, Università degli Studi di Padova, Padova
| | | | - Andrea Giusti
- Bone Clinic, Dipartimento delle Cure Geriatriche, Ortogeriatria e Riabilitazione, Ospedale Galliera, Genova, Italia
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43
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Giusti A, Fusaro M. [The treatment of the patient presenting with chronic kidney disease (CKD) and fragility fractures]. G Ital Nefrol 2017; 34:2017-vol6-10. [PMID: 29207226] [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] [Indexed: 06/07/2023]
Abstract
Fragility fractures occur in all stages of chronic kidney disease (CKD) due to low bone mineral density and poor bone quality (namely osteoporosis), as well as in CKD-mineral and bone disorders (CKD-MBD). As in postmenopausal women and older adults, the prompt identification of CKD subjects with a history of fragility fractures is crucial in order to implement strategies to reduce the risk of new fragility fractures and their consequences. The treatment of severe osteoporosis for patients with stages 1-3 CKD should not differ from patients without CKD, while clinical decisions and pharmacological treatments in subjects with stages 4-5/5D CKD differ greatly, being more tricky and challenging. Before starting a pharmacological therapy in subjects with stages 4-5/5D CKD and a history of fragility fractures, it is imperative to discriminate between osteoporosis and CKD-MBD, using quantitative bone histomorphometry. After the implementation of general non-pharmacological measures for fractures and falls risk reduction, the management of osteoporotic patients in stages 4-5/5D CKD may include bisphosphonates and denosumab, though evidence for safety and efficacy is marginal in advanced CKD. Alendronate, risedronate and denosumab have been shown to be effective (in reducing fracture incidence), safe and well tolerated in stage 4 CKD. On the other hand, the pharmacological treatment in patients with stage 5/5D CKD has been explored only in small reports/series producing poor or limited evidence. In all cases (stages 4-5/5D), physicians should be aware of the potential risk of adverse events such as the adynamic bone disease or hypocalcaemia.
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Affiliation(s)
- Andrea Giusti
- Bone Clinic, Dipartimento delle Cure Geriatriche, Ortogeriatria e Riabilitazione, Ospedale Galliera, Genova, Italia
| | - Maria Fusaro
- Consiglio Nazionale delle Ricerche (CNR) - Istituto di Fisiologia Clinica (IFC), Pisa e Dipartimento di Medicina, Università di Padova
- Dipartimento di Medicina, Università degli Studi di Padova
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44
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Piscopo G, Morrone L. [ASSOCIATION BETWEEN VERTEBRAL FRACTURES AND VASCULAR CALCIFICATIONS]. G Ital Nefrol 2017; 34:2017-vol6-9. [PMID: 29207225] [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] [Indexed: 06/07/2023]
Abstract
Several cross-sectional and prospective studies highlight the existence of an association between bone fractures and abdominal aortic calcifications, especially if particularly severe and independent from confounders such as aging, smoking habits and diabetes. This phenomenon affects not only the general population but also patients with chronic kidney disease in which cortical bone lesions are prevalent. Moreover, bone fractures and aortic calcifications have been proved to be linked to increased cardiovascular morbidity and mortality, both in the general populations and in patients with chronic kidney disease, who notoriously show elevated cardiovascular risks. Therefore, diagnostic investigations about bone fractures and abdominal aortic calcifications, particularly in patients with chronic kidney disease, may represent a useful tool for identification of patients with a higher cardiovascular risk in order to optimize therapies for bone metabolism disorders.
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Affiliation(s)
| | - Luigi Morrone
- UOC Nefrologia e Dialisi, Ospedale SS Annunziata, Taranto
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45
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Dalle Carbonare L, Valenti MT. [Bone biopsy in the Chronic Kidney Disease (CKD)]. G Ital Nefrol 2017; 34:2017-vol6-8. [PMID: 29207224] [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] [Indexed: 06/07/2023]
Abstract
Histomorphometry or quantitative histology is the analysis on histologic sections of bone resorption, formation and structure parameters. It is the only technique allowing a dynamic evaluation of osteoblast activity after labelling with tetracycline. In addition, the use of computed image analyzer allows the possibility to assess bone microarchitecture. Histomorphometric bone biopsy is a reliable and well-tolerated procedure. Bone samples are taken at iliac crest level under local anesthesia and sedation. Samples are put into methyl-metacrilate resin where the sections are prepared for the microscopic analysis of different histomorphometric parameters. Histomorphometry is used to exclude or confirm the diagnosis of osteomalacia and also to evaluate bone damage associated with particular treatments (for example, glucocorticoids, anticonvulsants) or in case of rare bone diseases (osteogenesis imperfecta). Recently, this approach has been repurposed for the evaluation of bone disease during Chronic Kidney Disease, particularly to differentiate high and low bone turnover osteodystrophy. Kidney Disease Improving Global Outcomes (KDIGO) guidelines have pointed out the situations requiring bone biopsy for histomorphometric analysis. New techniques using molecular biology will improve the accuracy and predictive value of this approach.
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Affiliation(s)
- Luca Dalle Carbonare
- Department of Medicine, Section of Internal Medicine D, University of Verona, Italy
| | - Maria Teresa Valenti
- Department of Medicine, Section of Internal Medicine D, University of Verona, Italy
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46
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Pérez-Sáez MJ, Prieto-Alhambra D, Díez-Pérez A, Pascual J. Advances in the evaluation of bone health in kidney transplant patients. Nefrologia 2017; 38:27-33. [PMID: 29137893 DOI: 10.1016/j.nefro.2017.04.002] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 02/26/2017] [Accepted: 04/05/2017] [Indexed: 01/10/2023] Open
Abstract
Bone disease related to chronic kidney disease and, particularly, to kidney transplant patients is a common cause or morbidity and mortality, especially due to a higher risk of osteoporotic fractures. Despite the fact that this has been known for decades, to date, an appropriate diagnostic strategy has yet to be established. Apart from bone biopsy, which is invasive and scarcely used, no other technique is available to accurately establish the risk of fracture in kidney patients. Techniques applied to the general population, such as bone densitometry, have not been subjected to sufficient external validation and their use is not systematic. This means that the identification of patients at risk of fracture and therefore those who are candidates for preventive strategies is an unmet need. Bone strength, defined as the ability of the bone to resist fracture, is determined by bone mineral density (measured by bone densitometry), trabecular architecture and bone tissue quality. The trabecular bone score estimates bone microarchitecture, and low values have been described as an independent predictor of increased fracture risk. Bone microindentation is a minimally invasive technique that measures resistance of the bone to micro-cracks (microscopic separation of mineralised collagen fibres), and therefore bone tissue biomechanical properties. The superiority over bone densitometry of the correlation between the parameters measured by trabecular bone score and microindentation with the risk of fracture in diverse populations led us to test its feasibility in chronic kidney disease and kidney transplant patients.
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Affiliation(s)
- María José Pérez-Sáez
- Servicio de Nefrología, Hospital del Mar, Barcelona, España; Institut Mar d'Investigacions Mediques, Barcelona, España; REDinREN, Instituto Carlos III, Madrid, España
| | - Daniel Prieto-Alhambra
- Institut Mar d'Investigacions Mediques, Barcelona, España; Oxford NIHR Musculoskeletal Biomedical Research Unit. Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences. University of Oxford, Oxford, Inglaterra, Reino Unido; CIBERFES, Instituto Carlos III, Madrid, España
| | - Adolfo Díez-Pérez
- Institut Mar d'Investigacions Mediques, Barcelona, España; CIBERFES, Instituto Carlos III, Madrid, España; Servicio de Medicina Interna, Hospital del Mar, Universidad Autonóma de Barcelona, España
| | - Julio Pascual
- Servicio de Nefrología, Hospital del Mar, Barcelona, España; Institut Mar d'Investigacions Mediques, Barcelona, España; REDinREN, Instituto Carlos III, Madrid, España.
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47
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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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48
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Shroff R, Wan M, Nagler EV, Bakkaloğlu S, Fischer DC, Bishop N, Cozzolino M, Bacchetta J, Edefonti A, Stefanidis CJ, Vande Walle J, Haffner D, Klaus G, Schmitt CP. Clinical practice recommendations for native vitamin D therapy in children with chronic kidney disease Stages 2-5 and on dialysis. Nephrol Dial Transplant 2017; 32:1098-1113. [PMID: 28873969 PMCID: PMC5837199 DOI: 10.1093/ndt/gfx065] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [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: 11/22/2016] [Accepted: 03/15/2017] [Indexed: 01/10/2023] Open
Abstract
Vitamin D deficiency is widely prevalent and often severe in children and adults with chronic kidney disease (CKD). Although native vitamin D {25-hydroxyvitamin D [25(OH)D]} is thought to have pleiotropic effects on many organ systems, its skeletal effects have been most widely studied. The 25(OH)D deficiency is causally linked with rickets and fractures in healthy children and those with CKD, contributing to the CKD-mineral and bone disorder (MBD) complex. There are few studies to provide evidence for vitamin D therapy or guidelines for its use in CKD. A core working group (WG) of the European Society for Paediatric Nephrology (ESPN) CKD-MBD and Dialysis WGs have developed recommendations for the evaluation, treatment and prevention of vitamin D deficiency in children with CKD. We present clinical practice recommendations for the use of ergocalciferol (vitamin D2) and cholecalciferol (vitamin D3) in children with CKD Stages 2-5 and on dialysis. A parallel document addresses treatment recommendations for active vitamin D analogue therapy. The WG has performed an extensive literature review to include meta-analyses and randomized controlled trials in healthy children as well as children and adults with CKD, and prospective observational studies in children with CKD. The Grading of Recommendation, Assessment, Development and Evaluation (GRADE) system has been used to develop and grade the recommendations. In the absence of applicable study data, the opinion of experts from the ESPN CKD-MBD and Dialysis WGs is provided, but clearly GRADE-ed as such and must be carefully considered by the treating physician, and adapted to individual patient needs as appropriate.
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Affiliation(s)
- Rukshana Shroff
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Mandy Wan
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | | | | | | | - Mario Cozzolino
- Department of Health Sciences, Ospedale San Paolo, University of Milan, Milan, Italy
| | | | - Alberto Edefonti
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
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49
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Shroff R, Wan M, Nagler EV, Bakkaloğlu S, Cozzolino M, Bacchetta J, Edefonti A, Stefanidis CJ, Vande Walle J, Ariceta G, Klaus G, Haffner D, Schmitt CP. Clinical practice recommendations for treatment with active vitamin D analogues in children with chronic kidney disease Stages 2-5 and on dialysis. Nephrol Dial Transplant 2017; 32:1114-1127. [PMID: 28873971 PMCID: PMC5837664 DOI: 10.1093/ndt/gfx080] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [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: 11/22/2016] [Accepted: 04/01/2017] [Indexed: 01/11/2023] Open
Abstract
In patients with chronic kidney disease (CKD), renal synthesis of active vitamin D [1,25-dihydroxyvitamin D (1,25(OH)2D)] declines and is associated with hypocalcaemia, secondary hyperparathyroidism and the spectrum of CKD-mineral and bone disorder (MBD). In advanced CKD, active vitamin D analogues, including alfacalcidol, calcitriol and paricalcitol, are routinely administered. There are few studies on the use of vitamin D analogues in children with CKD and on dialysis. It is difficult to define bone-specific outcomes that can guide treatment with active vitamin D analogues in children with CKD-MBD. A core working group (WG) of the European Society for Paediatric Nephrology (ESPN) CKD-MBD and Dialysis WGs has developed recommendations for the use of active vitamin D therapy in children with CKD and on dialysis. A second document in parallel with this one covers treatment recommendations for native vitamin D therapy. The WGs have performed an extensive literature review to include systematic reviews and randomized controlled trials in adults and children with CKD and prospective observational studies in children with CKD. The Grading of Recommendation, Assessment, Development and Evaluation (GRADE) system was used to develop and grade the recommendations. In the absence of applicable study data, the opinion of experts from the ESPN CKD-MBD and Dialysis WGs is provided, but clearly GRADE-ed as such and must be carefully considered by the treating physician and adapted to individual patient needs as appropriate.
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Affiliation(s)
- Rukshana Shroff
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Mandy Wan
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | | | - Mario Cozzolino
- Ospedale San Paolo, Department of Health Sciences, University of Milan, Milan, Italy
| | | | - Alberto Edefonti
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | | | - Gema Ariceta
- Servicio de Nefrología Pediátrica, Hospital Universitari Vall d'Hebron, Barcelona, España
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Abstract
PURPOSE OF REVIEW Bisphosphonates (BPs) have long been the gold-standard anti-remodeling treatment for numerous metabolic bone diseases. Since these drugs are excreted unmetabolized through the kidney, they are not recommended for individuals with compromised kidney function due to concerns of kidney and bone toxicity. The goal of this paper is to summarize the preclinical BP work in models of kidney disease with particular focus on the bone, kidney, and vasculature. RECENT FINDINGS Summative data exists showing positive effects on bone and vascular calcifications with minimal evidence for bone or kidney toxicity in animal models. Preclinical data suggest it may be worthwhile to take a step back and reconsider the use of bisphosphonates to lessen skeletal/vascular complications associated with compromised kidney function.
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Affiliation(s)
- Matthew R Allen
- Department of Anatomy and Cell Biology, Indiana University School of Medicine, Indianapolis, IN, USA.
- Department of Medicine/Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA.
- Department of Biomedical Engineering, Indiana University-Purdue University of Indianapolis, Indianapolis, IN, USA.
- Roudebush Veterans Administration Medical Center, Indianapolis, IN, USA.
| | - Mohammad W Aref
- Department of Anatomy and Cell Biology, Indiana University School of Medicine, Indianapolis, IN, USA
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