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Li J, Zhang W, Wang X, Sun N, Li L, Chang W. Peritoneal Phosphate Clearance: Determinants and Association With Mortality. Semin Dial 2024; 37:259-268. [PMID: 38506151 DOI: 10.1111/sdi.13205] [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: 01/21/2023] [Revised: 01/14/2024] [Accepted: 02/18/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND Dialytic phosphate removal is a cornerstone of the management of hyperphosphatemia in peritoneal dialysis (PD) patients, but the influencing factors on peritoneal phosphate clearance (PPC) are incompletely understood. Our objective was to explore clinically relevant factors associated with PPC in patients with different PD modality and peritoneal transport status and the association of PPC with mortality. METHODS This is a cross-sectional and prospective observational study. Four hundred eighty-five PD patients were enrolled and divided into 2 groups according to PPC. All-cause mortality was evaluated after followed-up for at least 3 months. RESULTS High PPC group showed lower mortality compared with Low PPC group by Kaplan-Meier analysis and log-rank test. Both multivariate linear regression and multivariate logistic regression revealed that high transport status, total effluent dialysate volume per day, continuous ambulatory PD (CAPD), and protein in total effluent dialysate volume appeared to be positively correlated with PPC; body mass index (BMI) and the normalized protein equivalent of total nitrogen appearance (nPNA) were negatively correlated with PPC. Besides PD modality and membrane transport status, total effluent dialysate volume showed a strong relationship with PPC, but the correlation differed among PD modalities. CONCLUSIONS Higher PPC was associated with lower all-cause mortality risk in PD patients. Higher PPC correlated with CAPD modality, fast transport status, higher effluent dialysate volume and protein content, and with lower BMI and nPNA.
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Affiliation(s)
- Jinping Li
- Department of Nephrology, Tianjin First Central Hospital, Tianjin, China
| | - Wenyu Zhang
- Department of Nephrology, Tianjin First Central Hospital, Tianjin, China
| | - Xichao Wang
- Department of Nephrology, Tianjin First Central Hospital, Tianjin, China
| | - Na Sun
- Department of Nephrology, Tianjin First Central Hospital, Tianjin, China
| | - Lei Li
- Department of Nephrology, Tianjin First Central Hospital, Tianjin, China
| | - Wenxiu Chang
- Department of Nephrology, Tianjin First Central Hospital, Tianjin, China
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Navarrete JE, Ajiboye O, Lea JI. Biochemical markers of iron status and iron accumulation in peritoneal dialysis patients treated with ferric citrate. Perit Dial Int 2024; 44:133-140. [PMID: 37691436 DOI: 10.1177/08968608231197361] [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] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND Hyperphosphataemia is a common complication of kidney disease. Current dialysis techniques do not provide enough phosphorus clearance, hence the need to use phosphorus binders. Treatment options include calcium carbonate, calcium acetate, lanthanum carbonate, sevelamer hydrochloride and iron-based binders. Patients receiving peritoneal dialysis (PD) with sustained elevated ferritin levels exceeding 800 ng/mL are at a higher risk of death. We identify PD patients treated with iron-based binders and compare ferritin and risk of iron accumulation to patients treated with non-iron-based binders. METHODS All records of patients receiving PD at Emory dialysis centres until 30 October 2021 were reviewed for phosphorus binders. Basic demographics and laboratory data were time-referenced to the days on treatment with a particular binder. Patients were followed until discontinuation of the phosphorus binder, death, transplant, transfer to another dialysis provider or censoring at 36 months after medication was started. RESULTS Compared to calcium acetate and sevelamer, ferric citrate utilisation in PD patients resulted in a sustained increase in ferritin. The proportion of patients with a ferritin equal to or greater than 800 ng/dL and transferrin saturation greater than 40% increased over time in patients treated with ferric citrate and was higher during the second and third year of follow-up compared to baseline values and to patients treated with calcium acetate or sevelamer. Two patients (7%) treated with ferric citrate developed clinically significant haemosiderosis. CONCLUSIONS Use of ferric citrated in PD resulted in significant iron accumulation as judged by ferritin levels.
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Affiliation(s)
| | | | - Janice I Lea
- Renal Division, Emory University School of Medicine, USA
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Nakayama M, Kobayashi S, Kusakabe M, Ohara M, Nakanishi K, Akizawa T, Fukagawa M. Tenapanor for peritoneal dialysis patients with hyperphosphatemia: a phase 3 trial. Clin Exp Nephrol 2024; 28:153-164. [PMID: 37910313 PMCID: PMC10808471 DOI: 10.1007/s10157-023-02406-1] [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: 04/03/2023] [Accepted: 09/10/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Tenapanor is a novel selective inhibitor of intestinal sodium/hydrogen exchanger 3 transporter. This is the first trial to assess the efficacy and safety of tenapanor in Japanese patients with hyperphosphatemia who are undergoing peritoneal dialysis. METHODS This phase 3, open-label, multicenter, single-arm clinical trial targeted patients whose serum phosphorus was within 3.5-7.0 mg/dL with phosphate binders at screening. After phosphate binder washout, tenapanor was orally administered twice-daily, stepwise from 5 to 30 mg/dose for 16 weeks. The primary endpoint, mean change in serum phosphorus level, was evaluated at week 8. The 16-week treatment period was completed with tenapanor alone, and only one phosphate binder type was allowed for combined use after the primary endpoint. RESULTS Of the 54 patients enrolled, 34 completed the study. At week 8, the primary endpoint, mean change in serum phosphorus level (last observation carried forward), was - 1.18 mg/dL (95% confidence interval: - 1.54, - 0.81 mg/dL) with tenapanor. From a baseline value of 7.65 mg/dL, serum phosphorus decreased to 6.14 and 5.44 mg/dL at weeks 8 and 16, respectively, and 46.3% and 76.5% of patients achieved serum phosphorus within 3.5-6.0 mg/dL at week 8 and week 16, respectively. The most common adverse event, diarrhea, occurred in 74.1% of patients; the severity of diarrhea was mild or moderate. Thus, the discontinuation percentage due to diarrhea was low at 5.6%. CONCLUSIONS Administration of tenapanor resulted in a sufficient reduction in serum phosphorus level at week 8 and was considered safe and tolerable. TRIAL REGISTRATION NCT04766385.
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Affiliation(s)
- Masaaki Nakayama
- Kidney Center, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, 104-8560, Japan.
| | | | | | - Meiko Ohara
- R&D Division, Kyowa Kirin Co., Ltd., Tokyo, Japan
| | | | - Tadao Akizawa
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology, and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
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Medaura JA, Zhou M, Ficociello LH, Anger MS, Sprague SM. Serum Phosphorus Management with Sucroferric Oxyhydroxide as a First-Line Phosphate Binder within the First Year of Hemodialysis. Am J Nephrol 2023; 55:127-135. [PMID: 38091973 PMCID: PMC10994597 DOI: 10.1159/000535754] [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: 10/06/2023] [Accepted: 12/03/2023] [Indexed: 04/04/2024]
Abstract
INTRODUCTION Sucroferric oxyhydroxide (SO), a non-calcium, chewable, iron-based phosphate binder (PB), effectively lowers serum phosphorus (sP) concentrations while reducing pill burden relative to other PBs. To date, SO studies have largely examined treatment-experienced, prevalent hemodialysis populations. We aimed to explore the role of first-line SO initiated during the first year of dialysis. METHODS We retrospectively analyzed deidentified data from adults receiving in-center hemodialysis who were prescribed SO monotherapy within the first year of hemodialysis as part of routine clinical care. All patients continuing SO monotherapy for 12 months were included. Changes from baseline in sP, achievement of sP ≤5.5 and ≤4.5 mg/dL, and other laboratory parameters were analyzed quarterly for 1 year. RESULTS The overall cohort included 596 patients, 286 of whom had a dialysis vintage ≤3 months. In the 3 months preceding SO initiation, sP rapidly increased (mean increases of 1.02 and 1.65 mg/dL in the overall cohort and incident cohort, respectively). SO treatment was associated with significant decreases in quarterly sP (mean decreases of 0.26-0.36; p < 0.0001 for each quarter and overall). While receiving SO, 55-60% of patients achieved sP ≤5.5 mg/dL and 21-24% achieved sP ≤4.5 mg/dL (p < 0.0001 for each quarter and overall vs. baseline). Daily PB pill burden was approximately 4 pills. Serum calcium concentrations increased and intact parathyroid hormone concentrations decreased during SO treatment (p < 0.0001 vs. baseline). CONCLUSIONS Among patients on hemodialysis, initiating SO as a first-line PB resulted in significant reductions in sP while maintaining a relatively low PB pill burden.
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Affiliation(s)
- Juan A Medaura
- Touro Infirmary, LCMC Health, New Orleans, Louisiana, USA
| | - Meijiao Zhou
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts, USA,
| | - Linda H Ficociello
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts, USA
| | - Michael S Anger
- Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts, USA
| | - Stuart M Sprague
- Division of Nephrology and Hypertension, NorthShore University Health System-University of Chicago Pritzker School of Medicine, Evanston, Illinois, USA
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Leypoldt JK, Echeverri J, Harenski K, Singh K. Predictions of Serum Phosphate Concentration during Continuous Renal Replacement Therapy Using a Steady-State Mass Balance Model. Blood Purif 2023; 53:40-48. [PMID: 37926075 DOI: 10.1159/000533322] [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: 01/31/2023] [Accepted: 07/24/2023] [Indexed: 11/07/2023]
Abstract
INTRODUCTION Hypophosphatemia is common during continuous renal replacement therapy (CRRT), but serum phosphate levels can potentially be maintained during treatment by either intravenous phosphate supplementation or addition of phosphate to renal replacement therapy (RRT) solutions. METHODS We developed a steady-state phosphate mass balance model to assess the effects of CRRT dose on serum phosphate concentration when using both phosphate-free and phosphate-containing RRT solutions, with emphasis on low CRRT doses. RESULTS The model predicted that measurements of serum phosphate concentration prior to (initial) and during CRRT (final) together with clinical data on CRRT dose, treatment duration, and phosphate supplementation can determine model patient parameters, that is, both the initial generation rate and clearance of phosphate prior to CRRT. Model parameters were then calculated from average patient data reported in several previous publications with a standard or high CRRT dose. Using representative model parameters for typical patients, predictions were then made of the effect of low CRRT dose on the change in serum phosphate levels after implementation of CRRT. The model predicted that CRRT at a low dose using phosphate-free RRT solutions will limit, but not eliminate, the incidence of hypophosphatemia. Further, the model predicted that CRRT at a low dose will have virtually no influence on the incidence of hyperphosphatemia when using phosphate-containing RRT solutions. CONCLUSIONS This report identifies the clinical measurements to be used with the proposed model for individualizing the CRRT dose and RRT phosphate concentration to maintain serum phosphate concentrations in a desired range.
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Affiliation(s)
- John K Leypoldt
- Department IV - Modeling and Supporting of Internal Functions, Nalecz Institute of Biocybernetics and Biomedical Engineering Polish Academy of Sciences, Warsaw, Poland
| | - Jorge Echeverri
- Global Medical Affairs, Baxter Healthcare Corporation, Deerfield, Illinois, USA
| | - Kai Harenski
- Global Medical Affairs, Baxter Deutschland GmbH, Unterschleissheim, Germany
| | - Kuljinder Singh
- Medical Affairs Japan and ANZ, Baxter International, Tokyo, Japan
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Silva AL, Chertow GM, Hernandez GT, Lynn RI, Tietjen DP, Rosenbaum DP, Yang Y, Edelstein S. Tenapanor Improves Long-Term Control of Hyperphosphatemia in Patients Receiving Maintenance Dialysis: the NORMALIZE Study. Kidney360 2023; 4:1580-1589. [PMID: 37853560 PMCID: PMC10695649 DOI: 10.34067/kid.0000000000000280] [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] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 10/11/2023] [Indexed: 10/20/2023]
Abstract
Key Points Tenapanor is a first-in-class, minimally systemic sodium–hydrogen exchanger 3 inhibitor with a mechanism of action distinct from phosphate binders. Tenapanor alone or with phosphate binders led to 35%–49% of patients achieving serum phosphate ≤4.5 mg/dl over an 18-month period versus 22% at baseline. Tenapanor alone or with phosphate binders may help adults with CKD on maintenance dialysis achieve normal serum phosphate concentrations. Background Most patients with ESKD and hyperphosphatemia have difficulty controlling serum phosphate (sP) concentrations despite maintenance dialysis, dietary restriction, and phosphate binder treatment. NORMALIZE evaluated the efficacy and safety of tenapanor 30 mg twice daily alone or in combination with phosphate binders to achieve sP within the adult population reference range (2.5–4.5 mg/dl). Methods Patients who completed the Phase 3 PHREEDOM study could enroll in NORMALIZE. Patients enrolled in NORMALIZE who had received tenapanor during the PHREEDOM study (n =111) added sevelamer carbonate if sP was >4.5 mg/dl. Patients who had received sevelamer carbonate during the PHREEDOM study (n =61) added tenapanor and decreased sevelamer carbonate if sP was ≤4.5 mg/dl, per protocol titration schedule. Patients were followed in NORMALIZE for up to 18 months. We assessed efficacy in the full analysis set, defined as patients who received ≥1 dose of study drug and had ≥1 post-treatment sP measurement (n =171). We assessed safety in all patients who received ≥1 dose of study drug (n =172). Results At the end point visit, 57 of 171 patients (33%) in the full analysis set achieved sP between 2.5 and 4.5 mg/dl. Eight of 23 patients (35%) who were on tenapanor alone at the end point visit achieved sP between 2.5 and 4.5 mg/dl. The mean reduction from PHREEDOM baseline to end of NORMALIZE in sP was 2.0 mg/dl. Serum intact fibroblast growth factor-23 was significantly reduced; serum intact parathyroid hormone was significantly reduced among patients with intact parathyroid hormone ≥300 pg/ml at PHREEDOM baseline. The most commonly reported treatment-emergent adverse event was diarrhea in 38 of 172 patients (22%), which led to tenapanor discontinuation in four patients (2%). Conclusions Tenapanor alone or in combination with phosphate binders helped adult patients on maintenance dialysis achieve normal sP concentrations. Safety was consistent with previous studies of tenapanor. Clinical trial registry name and registration number A Long-Term Study to Evaluate the Ability of Tenapanor Alone or in Combination With Sevelamer to Treat to Goal Serum Phosphorus in Patients With ESKD on Dialysis (NORMALIZE), NCT03988920 .
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Affiliation(s)
| | - Glenn M. Chertow
- Departments of Medicine and Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California
| | | | | | | | | | - Yang Yang
- Ardelyx, Inc., Waltham, Massachusetts
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Wang Y, Chen X, Zhu H, Guo Z, Yang Y, Luo P, He Y, Xu Y, Ji D, Gao X, Sun X, Xing C, Wang Y, Wang X, Zhao S, Guan Y, Lin H, Zhong A, Shui H, Shao F, Lv L, Yan Y, Sun X, Zhang L. Efficacy and Safety of Ferric Citrate on Hyperphosphatemia among Chinese Patients with Chronic Kidney Disease Undergoing Hemodialysis: A Phase III Multicenter Randomized Open-Label Active-Drug-Controlled Study. Am J Nephrol 2023; 54:479-488. [PMID: 37812931 DOI: 10.1159/000534484] [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] [Received: 07/21/2023] [Accepted: 10/02/2023] [Indexed: 10/11/2023]
Abstract
INTRODUCTION Hyperphosphatemia in chronic kidney disease (CKD) patients is positively associated with mortality. Ferric citrate is a potent phosphorus binder that lowers serum phosphorus level and improves iron metabolism. We compared its efficacy and safety with active drugs in Chinese CKD patients with hemodialysis. METHODS Chinese patients undergoing hemodialysis were randomized into two treatment groups in a 1:1 ratio, receiving either ferric citrate or sevelamer carbonate, respectively, for 12 weeks. Serum phosphorus levels, calcium concentration, and iron metabolism parameters were evaluated every 2 weeks. Frequency and severity of adverse events were recorded. RESULTS 217 (90.4%) patients completed the study with balanced demographic and baseline characteristics between two groups. Ferric citrate decreased the serum phosphorus level to 0.59 ± 0.54 mmol/L, comparable to 0.56 ± 0.62 mmol/L by sevelamer carbonate. There was no significant difference between two groups (p > 0.05) in the proportion of patients with serum phosphorus levels reaching the target range, the response rate to the study drug, and the changes of corrected serum calcium concentrations, and intact-PTH levels at the end of treatment. The change of iron metabolism indicators in the ferric citrate group was significantly higher than those in the sevelamer carbonate group. There are 47 (40.5%) patients in the ferric citrate group, and 26 (21.3%) patients in the sevelamer carbonate group experienced drug-related treatment emergent adverse events (TEAEs); most were mild and tolerable. Common drug-related TEAEs were gastrointestinal disorders, including diarrhea (12.9 vs. 2.5%), fecal discoloration (14.7 vs. 0%), and constipation (1.7 vs. 7.4%) in ferric citrate and sevelamer carbonate group. CONCLUSION Ferric citrate capsules have good efficacy and safety in the control of hyperphosphatemia in adult patients with CKD undergoing hemodialysis. Efficacy is not inferior to sevelamer carbonate. The TEAEs were mostly mild and tolerated by the patients.
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Affiliation(s)
- Yong Wang
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Nephrology Institute of the Chinese People's Liberation Army, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research, Beijing, China
| | | | - Hanyu Zhu
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Nephrology Institute of the Chinese People's Liberation Army, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research, Beijing, China
| | - Zhiyong Guo
- Department of Nephrology, Changhai Hospital of Shanghai, Naval Medical University, Shanghai, China
| | - Yibin Yang
- Department of Nephrology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Ping Luo
- Department of Nephrology, The Second Hospital of Jilin University, Changchun, China
| | - Yani He
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| | - Yan Xu
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Daxi Ji
- Department of Nephrology, Nanjing BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, China
| | - Xinlu Gao
- Department of Nephrology, Jiujiang University Affiliated Hospital, Jiujiang, China
| | - Xiuli Sun
- Department of Nephrology, Baotou City Central Hospital, Baotou, China
| | - Changying Xing
- Department of Nephrology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Yu Wang
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiaohui Wang
- Department of Nephrology, Wuhan Fifth Hospital, Wuhan, China
| | - Shuping Zhao
- Department of Endocrinology and Nephrology, Central Hospital of Tonghua, Tonghua, China
| | - Yan Guan
- Department of Nephrology, Meihekou City Central Hospital, Meihekou, China
| | - Hongli Lin
- Department of Nephrology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Aimin Zhong
- Department of Nephrology, Jiangxi Provincial People's Hospital, Nanchang, China
| | - Hua Shui
- Department of Nephrology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Fengmin Shao
- Department of Nephrology, Henan Provincial People's Hospital, Zhengzhou, China
| | - Lu Lv
- Department of Nephrology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, China
| | - Yuehong Yan
- Department of Nephrology, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xiaokun Sun
- Department of Nephrology, Jilin Guowen Hospital, Jilin, China
| | - Lei Zhang
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Nephrology Institute of the Chinese People's Liberation Army, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research, Beijing, China
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Luo H, Feng J, Zhang Y, Wang J, Xue G, Huang X, You S, Dong H, Li L, Li J, Xiao H, Ai X, Li X, Huang B. Efficacy and safety of tenapanor in hemodialysis patients with hyperphosphatemia: A systematic review and meta-analysis of randomized placebo-controlled trials. Ther Apher Dial 2023; 27:839-847. [PMID: 37349983 DOI: 10.1111/1744-9987.14028] [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: 04/26/2023] [Revised: 05/30/2023] [Accepted: 06/13/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND The effects of tenapanor in reducing serum phosphorus in hemodialysis patients with hyperphosphatemia are uncertain and no relevant meta-analysis has been conducted. We performed a meta-analysis of randomized placebo-controlled trials to evaluate the efficacy and safety of tenapanor. METHODS All randomized controlled trials of tenapanor were searched up to 1 August 2022. The primary endpoint was the change in serum phosphorus level from baseline with tenapanor and placebo. Data on drug-related adverse events (AEs), gastrointestinal AEs and diarrhea were collected to determine the safety of tenapanor. RESULTS There were 533 patients throughout five trials that were eligible. Tenapanor significantly lowered blood phosphorus level by 1.79 mg/dl in the mean difference than the placebo. Diarrhea, gastrointestinal AEs, and drug-related AEs were more severe than placebo. CONCLUSIONS This meta-analysis showed that although drug side effects were common, tenapanor significantly reduced serum phosphorus level in hemodialysis patients.
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Affiliation(s)
- Houli Luo
- Department of Radiology, Cheng du First People's Hospital, Chengdu, Sichuan, China
| | - Jian Feng
- Department of Critical Care Medicine, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Yanbiao Zhang
- Department of Burn and Plastic, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Jie Wang
- Department of Critical Care Medicine, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Gang Xue
- Department of Burn and Plastic, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Xi Huang
- Department of Burn and Plastic, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Shuang You
- Department of Burn and Plastic, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Hongfei Dong
- Department of Burn and Plastic, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Lingfan Li
- Department of Burn and Plastic, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Juncheng Li
- Department of Burn and Plastic, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Hualin Xiao
- Department of Burn and Plastic, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Xiang Ai
- Department of Burn and Plastic, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Xianhui Li
- Department of Burn and Plastic, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Bo Huang
- Department of Burn and Plastic, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
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Tanaka A, Sasaki S, Noma H, Wang J, Onishi Y, Inaguma D. Effects of iron-based phosphate binders on mortality and cardiovascular events in patients receiving maintenance dialysis. Sci Rep 2023; 13:16051. [PMID: 37749304 PMCID: PMC10520071 DOI: 10.1038/s41598-023-43177-9] [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: 06/11/2023] [Accepted: 09/20/2023] [Indexed: 09/27/2023] Open
Abstract
Phosphate binders are the main treatment for hyperphosphatemia in patients with chronic kidney disease, and iron-based phosphate binders have been used with increasing frequency in recent years. This study examined the association of the use of iron-based, rather than non-iron-based, phosphate binders with the incidence of cardiovascular events, in a real-world setting. We used data from a cohort comprising representative adult patients on maintenance hemodialysis in Japan. The exposure of interest was the time-varying use of phosphate binders, classified into "iron-based", "only non-iron-based", and "no use". The primary outcome was a composite of cardiovascular events and all-cause deaths. A marginal structural Cox regression model was used to deal with possible time-dependent confounding. Of the 2247 patients from 58 hemodialysis facilities, iron-based and only non-iron-based phosphate binders were used in 328 (15%) and 1360 (61%), respectively, at baseline. Hazard ratios (95% confidence intervals) for iron-based and non-iron-based phosphate binders versus no use of phosphate binders were 0.35 (0.24, 0.52) and 0.44 (0.33, 0.58), respectively. The hazard ratio for iron-based relative to non-iron-based phosphate binders was 0.81 (0.58, 1.13), which was not statistically significant. Further studies are warranted to elucidate whether the use of iron-based phosphate binders reduces the event rate.
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Affiliation(s)
- Akihito Tanaka
- Department of Nephrology, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Sho Sasaki
- Section of Education for Clinical Research, Kyoto University Hospital, Kyoto, Japan
- Center for Innovative Research for Communities and Clinical Excellence (CiRC2LE), Fukushima Medical University, Fukushima, Japan
| | - Hisashi Noma
- Department of Data Science, The Institute of Statistical Mathematics, Tachikawa, Tokyo, Japan
| | - Jui Wang
- College of Public Health, National Taiwan University, Taipei, Taiwan
- Institute for Health Outcomes & Process Evaluation Research (iHope International), Kyoto, Japan
| | - Yoshihiro Onishi
- Institute for Health Outcomes & Process Evaluation Research (iHope International), Kyoto, Japan
| | - Daijo Inaguma
- Department of Internal Medicine, Fujita Health University Bantane Hospital, Otohbashi 3-6-10, Nakagawa-ku, Nagoya, Aichi, 454-8509, Japan.
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Vasli P, Hosseini M, Nasiri M, Bakhtiari N. Family-centered empowerment approach to optimize phosphate management among hemodialysis patients: an experimental study. BMC Nephrol 2023; 24:259. [PMID: 37661281 PMCID: PMC10476304 DOI: 10.1186/s12882-023-03311-1] [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: 12/05/2022] [Accepted: 08/26/2023] [Indexed: 09/05/2023] Open
Abstract
BACKGROUND This study aimed to investigate the effect of a family-centered empowerment program on hyperphosphatemia management. METHOD This experimental study was performed on 80 randomly selected eligible patients with hyperphosphatemia undergoing hemodialysis. Patients were assigned randomly to two groups of family-centered empowerment program (FCEPG) and control group (CG) by coin toss (40 people per group). Data collection tools were the researcher-made Phosphate Control Knowledge Scale, the researcher-made Adherence to Dietary Restriction of Phosphorus Intake Scale, the eight-item Morisky Medication Adherence Scale, and serum phosphorus measurements. Data were collected before the intervention, one month, and three months after the intervention. Patients in FCEPG participated in a family-centered empowerment program. The statistical significance level was considered to be 0.05. RESULTS Inter-group comparisons showed no significant difference between FCEPG and CG in terms of the mean score of knowledge of phosphate control, adherence to dietary restriction of phosphorus intake, adherence to medication, and the mean serum phosphorus level before the empowerment program, but showed significant differences between them in these respects at one month after the program and three months after the program (p < 0.05). Intra-group comparisons showed a significant difference in FCEPG between the mean and standard deviation of all four variables before the empowerment program and the corresponding values one month and three months after the program (P < 0.05). CONCLUSION The findings of this study can be used in various fields of healthcare in the hospital and community.
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Affiliation(s)
- Parvaneh Vasli
- Department of Community Health Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Meimanat Hosseini
- Department of Community Health Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Malihe Nasiri
- Department of Basic Sciences, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Noushin Bakhtiari
- Department of Community Health Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Cernaro V, Longhitano E, Calabrese V, Casuscelli C, Di Carlo S, Spinella C, Gembillo G, Santoro D. Progress in pharmacotherapy for the treatment of hyperphosphatemia in renal failure. Expert Opin Pharmacother 2023; 24:1737-1746. [PMID: 37527180 DOI: 10.1080/14656566.2023.2243817] [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: 03/11/2023] [Revised: 07/26/2023] [Accepted: 07/31/2023] [Indexed: 08/03/2023]
Abstract
INTRODUCTION Among the clinical and metabolic complications of progressive chronic kidney disease (CKD), CKD-mineral bone disorder (CKD-MBD) significantly contributes to morbidity and mortality. While overt and persistent hyperphosphatemia is typical of advanced CKD and requires treatment, other abnormalities of calcium/phosphate metabolism begin to occur since the early stages of the disease. AREAS COVERED We searched on the PubMed database, without restrictions for language or time range, for randomized clinical trials and meta-analyses investigating phosphate-lowering therapies. The various phosphate binders show different safety profiles and diverse effects on calcium/phosphate metabolism and vascular calcification. The in-depth knowledge of the characteristics of these drugs is crucial to ensure adequate treatment to CKD patients. EXPERT OPINION A proper control of serum phosphate can be achieved using phosphate binders. These medications may induce side effects. Moreover, data on their impact on clinical outcomes are partly controversial or scarce, especially for the new generation drugs. Hyperphosphatemia favors cardiovascular disease and increases the risk for CKD progression. These effects are partially mediated by fibroblast growth factor 23 (FGF23), a phosphaturic hormone that raises to maintain normal serum phosphate. Since there are no data supporting the use of phosphate-lowering agents when phosphataemia is normal, a key role is played by reducing dietary phosphate intake with the aim to control serum phosphate and the compensatory FGF23 and parathyroid hormone (PTH) increase.
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Affiliation(s)
- Valeria Cernaro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Elisa Longhitano
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Vincenzo Calabrese
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Chiara Casuscelli
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Silvia Di Carlo
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Claudia Spinella
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Guido Gembillo
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Domenico Santoro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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12
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Luo H, Feng J, Xue G, Zhang Y, Li Y, Huang X, Chen X, You S, Dong H, Li L, Li J, Xiao H, Ai X, Li X, Huang B. Comparative Efficacy and Acceptability of 12 Phosphorus-Lowering Drugs in Adults with Hyperphosphatemia and Chronic Kidney Disease: A Systematic Review and Network Meta-Analysis. Blood Purif 2023; 52:609-620. [PMID: 37591223 DOI: 10.1159/000531577] [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: 11/20/2022] [Accepted: 06/09/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Hyperphosphatemia is associated with cardiovascular morbidity and mortality in adults with chronic kidney disease (CKD). Drug therapy has an irreplaceable role in the management of hyperphosphatemia. OBJECTIVES We aimed to compare and rank phosphorus-lowering drugs, including phosphate binder and nonphosphate binder, in hyperphosphatemia adults with CKD. METHODS We did a systematic review and frequentist random-effect network meta-analysis. We searched in PubMed, Cochrane Library, Web of Science, and Embase from inception to February 1, 2023, for randomized controlled trials of 12 phosphorus-lowering drugs in adults with hyperphosphatemia and CKD. Primary outcomes were efficacy (changes in serum phosphorus) and acceptability (treatment withdrawals due to any cause). We ranked each drug according to the value of surface under the cumulative ranking curve. We applied the Confidence in Network Meta-Analysis frameworks to rate the certainty of evidence. This study was registered with PROSPERO, number CRD42022322270. RESULTS We identified 2,174 citations, and of these, we included 94 trials comprising 14,459 participants and comparing 13 drugs or placebo. In terms of efficacy, except for niacinamide, all drugs lowered the level of serum phosphorus compared with placebo, with mean difference ranging between -1.61 (95% credible interval [CrI], -2.60 to -0.62) mg/dL for magnesium carbonate and -0.85 (-1.66 to -0.05) mg/dL for bixalomer. Only ferric citrate with odds ratios 0.56 (95% CrI: 0.36-0.89) was significantly associated with fewer dropouts for acceptability. Of the 94 trials, 43 (46%), 7 (7%), and 44 (47%) trials were rated as high, moderate, and low risk of bias, respectively, the certainty of the evidence was moderate to very low. CONCLUSIONS Magnesium carbonate has the best phosphorus-lowering effect in hyperphosphatemia adults with CKD; considering efficacy and acceptability, ferric citrate shows evidence to be the most appropriate drug with or without dialysis.
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Affiliation(s)
- Houli Luo
- Department of Radiology, Chengdu First People's Hospital, Chengdu, China
| | - Jian Feng
- Department of Critical Care Medicine, The General Hospital of Western Theater Command, Chengdu, China
| | - Gang Xue
- Department of Burn and Plastic, The General Hospital of Western Theater Command, Chengdu, China
| | - Yanbiao Zhang
- Department of Burn and Plastic, The General Hospital of Western Theater Command, Chengdu, China
| | - Yunming Li
- Department of Information, The General Hospital of Western Theater Command, Chengdu, China
| | - Xi Huang
- Department of Burn and Plastic, The General Hospital of Western Theater Command, Chengdu, China
| | - Xin Chen
- Department of Neurosurgery, The General Hospital of Western Theater Command, Chengdu, China
| | - Shuang You
- Department of Burn and Plastic, The General Hospital of Western Theater Command, Chengdu, China
| | - Hongfei Dong
- Department of Burn and Plastic, The General Hospital of Western Theater Command, Chengdu, China
| | - Lingfan Li
- Department of Burn and Plastic, The General Hospital of Western Theater Command, Chengdu, China
| | - Juncheng Li
- Department of Burn and Plastic, The General Hospital of Western Theater Command, Chengdu, China
| | - Hualin Xiao
- Department of Burn and Plastic, The General Hospital of Western Theater Command, Chengdu, China
| | - Xiang Ai
- Department of Burn and Plastic, The General Hospital of Western Theater Command, Chengdu, China
| | - Xianhui Li
- Department of Burn and Plastic, The General Hospital of Western Theater Command, Chengdu, China
| | - Bo Huang
- Department of Burn and Plastic, The General Hospital of Western Theater Command, Chengdu, China
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13
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Yasmine M, Hanene LF, Dorra BN, Zied J, Dhia K, Kaouther M, Mourad J, Wafa H. Tumor calcinosis revealing a familial hyperphosphatemic disease. Int J Rheum Dis 2023; 26:1619-1621. [PMID: 37031367 DOI: 10.1111/1756-185x.14687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 02/20/2023] [Accepted: 03/20/2023] [Indexed: 04/10/2023]
Affiliation(s)
- Makhlouf Yasmine
- Department of Rheumatology, Mohammed Kassab National Institute of Orthopedics, Mannouba, Tunisia
- Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
- Research Unit UR17SP04, 2010, Ksar Said, Tunis, 2010, Tunisia
| | - Lassoued Ferjani Hanene
- Department of Rheumatology, Mohammed Kassab National Institute of Orthopedics, Mannouba, Tunisia
- Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
- Research Unit UR17SP04, 2010, Ksar Said, Tunis, 2010, Tunisia
| | - Ben Nessib Dorra
- Department of Rheumatology, Mohammed Kassab National Institute of Orthopedics, Mannouba, Tunisia
- Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
- Research Unit UR17SP04, 2010, Ksar Said, Tunis, 2010, Tunisia
| | - Jlalia Zied
- Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
- Department of Pediatric Orthopedics, Mohammed Kassab National Institute of Orthopedics, Mannouba, Tunisia
| | - Kaffel Dhia
- Department of Rheumatology, Mohammed Kassab National Institute of Orthopedics, Mannouba, Tunisia
- Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
- Research Unit UR17SP04, 2010, Ksar Said, Tunis, 2010, Tunisia
| | - Maatallah Kaouther
- Department of Rheumatology, Mohammed Kassab National Institute of Orthopedics, Mannouba, Tunisia
- Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
- Research Unit UR17SP04, 2010, Ksar Said, Tunis, 2010, Tunisia
| | - Jenzri Mourad
- Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
- Department of Pediatric Orthopedics, Mohammed Kassab National Institute of Orthopedics, Mannouba, Tunisia
| | - Hamdi Wafa
- Department of Rheumatology, Mohammed Kassab National Institute of Orthopedics, Mannouba, Tunisia
- Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
- Research Unit UR17SP04, 2010, Ksar Said, Tunis, 2010, Tunisia
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Liu J, Zuo L, Walpen S, Bernard L, Marty M, Enoiu M. Efficacy and Safety of Sucroferric Oxyhydroxide Compared with Sevelamer Carbonate in Chinese Dialysis Patients with Hyperphosphataemia: A Randomised, Open-Label, Multicentre, 12-Week Phase III Study. Nephron Clin Pract 2023; 148:22-33. [PMID: 37473746 PMCID: PMC10794965 DOI: 10.1159/000531869] [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: 03/15/2023] [Accepted: 06/20/2023] [Indexed: 07/22/2023] Open
Abstract
INTRODUCTION This study aimed to investigate the efficacy and safety of sucroferric oxyhydroxide (SFOH) versus sevelamer carbonate in controlling serum phosphorus (sP) in adult Chinese dialysis patients with hyperphosphataemia (sP >1.78 mmol/L). METHODS Open-label, randomised (1:1), active-controlled, parallel group, multicentre, phase III study of SFOH and sevelamer at starting doses corresponding to 1,500 mg iron/day and 2.4 g/day, respectively, with 8-week dose titration and 4-week maintenance (NCT03644264). Primary endpoint was non-inferiority analysis of change in sP from baseline to week 12. Secondary endpoints included sP over time and safety. RESULTS 415 patients were screened; 286 were enrolled and randomised (142 and 144 to SFOH and sevelamer, respectively). Mean (SD) baseline sP: 2.38 (0.57) and 2.38 (0.52) mmol/L, respectively. Mean (SD) change in sP from baseline to week 12: - 0.71 (0.60) versus -0.63 (0.52) mmol/L, respectively; difference (sevelamer minus SFOH) in least squares means (95% CI): 0.08 mmol/L (-0.02, 0.18) with the lower limit of 95% CI above the non-inferiority margin of -0.34 mmol/L. The SFOH group achieved target sP (1.13-1.78 mmol/L) earlier than the sevelamer group (56.5% vs. 32.8% at week 4) and with a lower pill burden (mean 3.7 vs. 9.1 tablets/day over 4 weeks of maintenance, respectively). Safety and tolerability of SFOH was consistent with previous studies, and no new safety signals were observed. CONCLUSION SFOH effectively reduced sP from baseline and was non-inferior to sevelamer after 12 weeks of treatment but had a lower pill burden in Chinese dialysis patients with hyperphosphataemia; SFOH benefit-risk profile is favourable in Chinese patients.
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Affiliation(s)
- Jun Liu
- NanFang Hospital of Southern Medical University, Guangzhou City, China
| | - Li Zuo
- Peking University People’s Hospital, Beijing, China
| | | | | | | | - Milica Enoiu
- Vifor Pharma Management Ltd., Glattbrugg, Switzerland
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15
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Bushinsky DA, Budden JJ, Kalra PA, Yuan J, Quinn CM, Epstein M. Patiromer Treatment in Patients With CKD, Hyperkalemia, and Hyperphosphatemia: A Post Hoc Analysis of 3 Clinical Trials. Am J Kidney Dis 2023; 82:97-104. [PMID: 36965827 DOI: 10.1053/j.ajkd.2023.01.444] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 05/05/2022] [Accepted: 01/12/2023] [Indexed: 03/27/2023]
Abstract
RATIONALE & OBJECTIVE Patients with chronic kidney disease (CKD), hyperkalemia (serum potassium [sK+]>5.0 mEq/L), and hyperphosphatemia experience poor clinical outcomes. Patiromer, a potassium binder that uses calcium as the exchange ion, may also reduce serum phosphorus (sP). We characterized the effect of patiromer on sP in patients with CKD, hyperkalemia, and hyperphosphatemia. STUDY DESIGN A post hoc pooled analysis of individual-level data from the AMETHYST-DN, OPAL-HK, and TOURMALINE trials of patiromer. SETTING & PARTICIPANTS Patients with CKD and hyperkalemia. EXPOSURE Patients treated with patiromer (8.4-33.6 g/day). OUTCOME Mean changes from baseline in sP, sK+, serum calcium (sCa2+), and serum magnesium (sMg2+) after 2 and 4 weeks of treatment. ANALYTICAL APPROACH Descriptive statistics to summarize pooled data on the study outcomes from the 3 studies. RESULTS We included 578 patients in the analysis. Of these participants, 86 patients (14.9%) had baseline hyperphosphatemia of whom 75.6% (65 of 86) had CKD stage 4/5 and 31.1% (153 of 492) with sP≤4.5mg/dL had CKD stage 4/5. Among the patients with elevated sP and sK+at baseline, the mean±SD reduction in sP and sK+after 4 weeks of patiromer treatment was-0.62±1.09mg/dL and-0.71± 0.51 mEq/L, respectively. Additionally, the mean±SD reduction in sMg2+in these patients was -0.25±0.23mg/dL while sCa2+remained unchanged. Both sMg2+and sCa2+remained within the normal range. Patiromer was generally well tolerated, and no serious adverse events were considered related to patiromer. LIMITATIONS These were post hoc analyses, no placebo comparison was performed due to the design of the original studies, and the follow-up period was limited to 4 weeks. CONCLUSIONS Reductions in sP and sK+to the normal range were observed after 2 weeks of patiromer treatment, and the reduction was sustained during 4 weeks of treatment among patients with non-dialysis-dependent CKD, hyperkalemia, and hyperphosphatemia. Future controlled trials are needed to establish if patiromer is useful to reduce both sK+and sP in hyperkalemic patients with CKD and hyperphosphatemia.
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Affiliation(s)
- David A Bushinsky
- University of Rochester School of Medicine and Dentistry, Rochester, New York.
| | | | - Philip A Kalra
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, United Kingdom
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16
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Sprague SM, Reddy G, Jermasek D, Gupta P. High Phosphate-Binding Capacity of Oxylanthanum Carbonate with a Low Medication Volume: Comparison with Commercially Available Phosphate Binders. Am J Nephrol 2023; 54:219-223. [PMID: 37231835 PMCID: PMC10614253 DOI: 10.1159/000530989] [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: 02/18/2023] [Accepted: 04/26/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND A key focus for chronic kidney disease management is phosphate control, but currently available binders have suboptimal phosphate-binding capacity, and their characteristics result in low adherence and poor phosphate regulation. Oxylanthanum carbonate, a novel compound that uses proprietary nanoparticle technology to deliver lanthanum, has the potential to combine high phosphate-binding capacity with good intake convenience, thus improving adherence and patient quality of life. The goal of this study was to assess the volume of oxylanthanum Carbonate required to bind 1 g of phosphate and compare it with other currently available phosphate binders to determine which binder allows for the highest normalized potency with the lowest daily medication volume. METHODS Six phosphate binders were assessed: ferric citrate, calcium acetate, lanthanum carbonate, sevelamer carbonate, sucroferric oxyhydroxide, and oxylanthanum carbonate. Table volume measurements were taken using fluid displacement in corn oil or water. Mean daily dose volume to bind 1 g of phosphate was calculated as volume per tablet multiplied by the mean number of tablets taken per day. Volume to bind 1 g of phosphate was calculated by dividing the volume per tablet by its in vivo binding capacity. RESULTS Oxylanthanum carbonate had the lowest mean volume, daily phosphate binder dose volume, and equivalent phosphate-binding dose volume (volume to bind 1 g of phosphate for each binder). CONCLUSIONS Oxylanthanum carbonate has the lowest daily phosphate binder dose volume and the smallest volume required to bind 1 g of phosphate compared to all other commercially available phosphate binders. A randomized trial that compares gastrointestinal tolerability across binders would be warranted to demonstrate acceptability and adherence in the target population.
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Affiliation(s)
- Stuart M. Sprague
- Division of Nephrology and Hypertension, NorthShore University Health System, Evanston, IL, USA
| | - Guru Reddy
- Preclinical Research and Development, Unicycive Therapeutics, Inc., Los Altos, CA, USA
| | - Douglas Jermasek
- Corporate Strategy, Unicycive Therapeutics, Inc., Los Altos, CA, USA
| | - Pramod Gupta
- Pharmaceutical and Business Operations, Unicycive Therapeutics, Inc., Los Altos, CA, USA
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17
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Berner T, Ferro C, Dieguez G, Metz S, Moore J, Szabo E, Kovesdy CP. Real-World Phosphate Binder Use among Dialysis-Dependent Patients with CKD. Nephron Clin Pract 2023; 147:583-590. [PMID: 36996774 DOI: 10.1159/000530230] [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: 09/02/2022] [Accepted: 03/09/2023] [Indexed: 04/01/2023] Open
Abstract
INTRODUCTION For patients with chronic kidney disease (CKD), the need for phosphate binder (PB) treatment peaks at onset of dialysis. This real-world study assessed rates of PB utilization and switching in patients with dialysis-dependent CKD (DD-CKD). METHODS We identified patients with PB utilization among those with prevalent DD-CKD using 2018-2019 Medicare Parts A/B/D data. Patients were assigned to cohorts based on primary (most frequently used) PB among calcium acetate, ferric citrate, lanthanum carbonate, sevelamer (hydrochloride and carbonate), sucroferric oxyhydroxide. We measured proportion of patients who were adherent (proportion of days covered >80%) and persistent (patients whose last 90 days of outpatient dialysis reported PB use). Net switching rates were calculated as the difference between switches to and from the primary agent. RESULTS We identified 136,912 patients with PB use. Proportion of patients adherent ranged from 63.8% (lanthanum carbonate) to 67.7% (sevelamer) and persistent from 85.1% (calcium acetate) to 89.5% (ferric citrate). Most patients (73%) used the same PB throughout the study. Overall, 20.5% of patients experienced one switch and 2.3% two or more. Positive net switching rates were observed for ferric citrate, sucroferric oxyhydroxide, and lanthanum carbonate (2-10%) but negative for sevelamer and calcium acetate (-2% to -7%). CONCLUSION Adherence and persistence rates were low with slight variation across PBs. Net positive switching occurred for ferric citrate, sucroferric oxyhydroxide, and lanthanum carbonate. Further studies are needed to determine the reasons for these findings and could identify opportunities for better control of phosphate levels among patients with CKD.
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Affiliation(s)
- Todd Berner
- Research and Development, Akebia Therapeutics Inc., Cambridge, Massachusetts, USA
| | | | | | - Steve Metz
- New York Practice, Milliman, Inc., New York, New York, USA
| | - Jennifer Moore
- Research and Development, Akebia Therapeutics Inc., Cambridge, Massachusetts, USA
| | - Erika Szabo
- Research and Development, Akebia Therapeutics Inc., Cambridge, Massachusetts, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Moroșan E, Popovici V, Elian V, Dărăban AM, Rusu AI, Licu M, Mititelu M, Karampelas O. The Impact of Medical Nutrition Intervention on the Management of Hyperphosphatemia in Hemodialysis Patients with Stage 5 Chronic Kidney Disease: A Case Series. Int J Environ Res Public Health 2023; 20:5049. [PMID: 36981958 PMCID: PMC10049720 DOI: 10.3390/ijerph20065049] [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] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/10/2023] [Accepted: 03/11/2023] [Indexed: 06/18/2023]
Abstract
The treatment and interdisciplinary management of patients with chronic kidney disease (CKD) continue to improve long-term outcomes. The medical nutrition intervention's role is to establish a healthy diet plan for kidney protection, reach blood pressure and blood glucose goals, and prevent or delay health problems caused by kidney disease. Our study aims to report the effects of medical nutrition therapy-substituting foods rich in phosphorus-containing additives with ones low in phosphates content on phosphatemia and phosphate binders drug prescription in stage 5 CKD patients with hemodialysis. Thus, 18 adults with high phosphatemia levels (over 5.5 mg/dL) were monitored at a single center. Everyone received standard personalized diets to replace processed foods with phosphorus additives according to their comorbidities and treatment with prosphate binder drugs. Clinical laboratory data, including dialysis protocol, calcemia, and phosphatemia, were evaluated at the beginning of the study, after 30 and 60 days. A food survey was assessed at baseline and after 60 days. The results did not show significant differences between serum phosphate levels between the first and second measurements; thus, the phosphate binders' initial doses did not change. After 2 months, phosphate levels decreased considerably (from 7.322 mg/dL to 5.368 mg/dL); therefore, phosphate binder doses were diminished. In conclusion, medical nutrition intervention in patients with hemodialysis significantly reduced serum phosphate concentrations after 60 days. Restricting the intake of processed foods containing phosphorus additives-in particularized diets adapted to each patient's comorbidities-and receiving phosphate binders represented substantial steps to decrease phosphatemia levels. The best results were significantly associated with life expectancy; at the same time, they showed a negative correlation with the dialysis period and participants' age.
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Affiliation(s)
- Elena Moroșan
- Department of Clinical Laboratory and Food Safety, Faculty of Pharmacy, “Carol Davila” University of Medicine and Pharmacy, 6 Traian Vuia Street, 020945 Bucharest, Romania
| | - Violeta Popovici
- Department of Microbiology and Immunology, Faculty of Dental Medicine, Ovidius University of Constanta, 7 Ilarie Voronca Street, 900684 Constanta, Romania
| | - Viviana Elian
- Department of Diabetes, Nutrition and Metabolic Diseases, “Carol Davila” University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, 050471 Bucharest, Romania
- Department of Diabetes, Nutrition and Metabolic Diseases, “Prof. Dr. N. C. Paulescu” National Institute of Diabetes, Nutrition and Metabolic Diseases, 030167 Bucharest, Romania
| | - Adriana Maria Dărăban
- Faculty of Pharmacy, “Vasile Goldiș” Western University of Arad, 86 Liviu Rebreanu Street, 310045 Arad, Romania
| | - Andreea Ioana Rusu
- Faculty of Pharmacy, “Vasile Goldiș” Western University of Arad, 86 Liviu Rebreanu Street, 310045 Arad, Romania
| | - Monica Licu
- Department of Medical Psychology, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
| | - Magdalena Mititelu
- Department of Clinical Laboratory and Food Safety, Faculty of Pharmacy, “Carol Davila” University of Medicine and Pharmacy, 6 Traian Vuia Street, 020945 Bucharest, Romania
| | - Oana Karampelas
- Department of Pharmaceutical Technology and Biopharmacy, Faculty of Pharmacy, “Carol Davila” University of Medicine and Pharmacy, 6 Traian Vuia Street, 020945 Bucharest, Romania
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Al-Ghamdi SMG, Almalki AH, Altowaijri A, Al-Gabash A, Kotsopoulos N. Health Economic Benefits of Introducing Sucroferric Oxyhydroxide in the Treatment of Patients with Chronic Kidney Disease under Dialysis in the Kingdom of Saudi Arabia. Saudi J Kidney Dis Transpl 2023; 34:100-110. [PMID: 38146718 DOI: 10.4103/1319-2442.391887] [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: 12/27/2023] Open
Abstract
Hyperphosphatemia is an electrolyte disorder highly prevalent in patients with chronic kidney disease undergoing hemodialysis (HD) that usually requires treatment with oral phosphate binders (PBs). Sucroferric oxyhydroxide (SO) is a calcium-free, iron-based PB indicated for the control of serum phosphorus. In the real-world setting, SO has shown clinical effectiveness with a lower pill burden and has also been associated with reduced hospital admission rates. This study aims to assess the potential economic benefits resulting from the introduction of SO to the health-care setting of the Kingdom of Saudi Arabia (KSA). An economic analysis using data from a retrospective real-world study that compared HD patients with uninterrupted SO prescriptions with patients who discontinued SO and switched to other PBs (oPBs). Annual drug costs for the estimated PB-eligible population in KSA were quantified. Costs per responder were estimated for all treatments. Hospital admissions' incidence rates were converted into annual inpatient cost savings and were deducted from drug costs to estimate the annual economic effect of SO versus oPBs. Sensitivity and breakeven analyses were also conducted. The eligible population for PB therapy in KSA was estimated at n = 14,748. Treating therapy-eligible populations exclusively with SO was estimated to generate annual inpatient cost-savings of SAR 107.4-119.4 million compared to treating the population with oPBs. The estimated economic effect signified overall annual savings ranging from SAR 82.8 to SAR 94.8 million when the population is treated with SO. Sensitivity analyses showed persistent cost savings. The estimated benefit-cost ratios showed that for every SAR 1 spent on SO, the expected return on investment was SAR 4.4-4.9. SO is an effective therapy that may result in substantial cost savings from reducing hospital admission costs that are attributable to hyperphosphatemia among HD patients.
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Affiliation(s)
- Saeed M G Al-Ghamdi
- Department of Medicine, Nephrology Section, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
- Department of Medicine, Nephrology Section, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Abdullah Hashim Almalki
- Department of Medicine, Nephrology Section, King Abdulaziz Medical City, Ministry of National Guard, Jeddah, Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Abdulaziz Altowaijri
- Clinical Insights and Innovation Director, Center of National Health Insurance, Riyadh, Saudi Arabia
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20
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Bangsgaard KO, Andersen M, Heaf JG, Ottesen JT. Bayesian parameter estimation for phosphate dynamics during hemodialysis. Math Biosci Eng 2023; 20:4455-4492. [PMID: 36896508 DOI: 10.3934/mbe.2023207] [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] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Hyperphosphatemia in patients with renal failure is associated with increased vascular calcification and mortality. Hemodialysis is a conventional treatment for patients with hyperphosphatemia. Phosphate kinetics during hemodialysis may be described by a diffusion process and modeled by ordinary differential equations. We propose a Bayesian model approach for estimating patient-specific parameters for phosphate kinetics during hemodialysis. The Bayesian approach allows us to both analyze the full parameter space using uncertainty quantification and to compare two types of hemodialysis treatments, the conventional single-pass and the novel multiple-pass treatment. We validate and test our models on synthetic and real data. The results show limited identifiability of the model parameters when only single-pass data are available, and that the Bayesian model greatly reduces the relative standard deviation compared to existing estimates. Moreover, the analysis of the Bayesian models reveal improved estimates with reduced uncertainty when considering consecutive sessions and multiple-pass treatment compared to single-pass treatment.
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Affiliation(s)
- Katrine O Bangsgaard
- Department of Applied Mathematics and Computer Science, Technical University of Denmark, Richard Petersens Plads, Building 324, 2800 Kongens Lyngby, Denmark
| | - Morten Andersen
- Centre for Mathematical Modeling - Human Health and Disease, Department of Science and Mathematics, Roskilde University, 4000 Roskilde, Denmark
| | - James G Heaf
- Department of Medicine, Zealand University Hospital, 4000 Roskilde, Denmark
| | - Johnny T Ottesen
- Centre for Mathematical Modeling - Human Health and Disease, Department of Science and Mathematics, Roskilde University, 4000 Roskilde, Denmark
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21
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Contreras Angulo M, Palacios García N, Ferreira de Vasconcelos Carvalho R, Nocete Aragón I, Sanz-Aranguez Ávila B, Campos Del Portillo R. Hyperphosphatemia during nutrition recovery in patients with severe anorexia nervosa. ENDOCRINOL DIAB NUTR 2022; 69:715-722. [PMID: 36437197 DOI: 10.1016/j.endien.2021.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 12/26/2021] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Anorexia nervosa (AN) is a disorder associated with many medical complications. Regarding phosphorus metabolism, the only recognized alteration is hypophosphatemia associated with refeeding syndrome. However, in our clinical practice, we have observed a high frequency of hyperphosphatemia in late phases of nutrition therapy in severely undernourished AN patients, which has barely been described. MATERIALS AND METHODS We carried out a retrospective study of patients with AN hospitalized for severe decompensation of the disease. RESULTS Eleven patients were included, all women, with a median age of 23 years [20-46] and a body mass index at admission of 12.2 kg/m2 [11.7-13.1]. Hyperphosphatemia was noted in 9 of the 11 cases (81.8%) with a median time to onset of 53 days [30-75]. The median peak serum phosphorus (P) level was 5.1 mg/dl [4.9-5.4]. An inverse relationship was found between the increase in P levels and phosphorus supplementation at the onset of admission. The magnitude of the P increase was associated with the body weight gain achieved during nutrition therapy. CONCLUSION Late hyperphosphatemia during nutrition therapy in severely undernourished AN patients affects more than 80% of cases. Body weight gain throughout nutrition therapy is a predictor of increased P levels.
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Affiliation(s)
- Macarena Contreras Angulo
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Madrid, Spain
| | - Nuria Palacios García
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Madrid, Spain
| | | | - Ignacio Nocete Aragón
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Madrid, Spain
| | - Belén Sanz-Aranguez Ávila
- Servicio de Psiquiatría, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Madrid, Spain
| | - Rocío Campos Del Portillo
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Madrid, Spain.
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22
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Duque EJ, Elias RM, Moysés RMA. Phosphate balance during dialysis and after kidney transplantation in patients with chronic kidney disease. Curr Opin Nephrol Hypertens 2022; 31:326-331. [PMID: 35703226 DOI: 10.1097/mnh.0000000000000802] [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: 11/25/2022]
Abstract
PURPOSE OF REVIEW In patients with chronic kidney disease (CKD), hyperphosphatemia is associated with several adverse outcomes, including bone fragility and progression of kidney and cardiovascular disease. However, there is a knowledge gap regarding phosphate balance in CKD. This review explores its current state, depending on the stage of CKD, dialysis modalities, and the influence of kidney transplantation. RECENT FINDINGS Adequate phosphate control is one of the goals of treatment for CKD-mineral and bone disorder. However, ongoing studies are challenging the benefits of phosphate-lowering treatment. Nevertheless, the current therapy is based on dietary restriction, phosphate binders, and optimal removal by dialysis. In the face of limited adherence, due to the high pill burden, adjuvant options are under investigation. The recent discovery that intestinal absorption of phosphate is mostly paracellular when the intraluminal concentration is adequate might help explain why phosphate is still well absorbed in CKD, despite the lower levels of calcitriol. SUMMARY Future studies could confirm the benefits of phosphate control. Greater understanding of the complex distribution of phosphate among the body compartments will help us define a better therapeutic strategy in patients with CKD.
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Affiliation(s)
- Eduardo J Duque
- Laboratorio de Fisiopatologia Renal LIM16, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo
| | - Rosilene M Elias
- Laboratorio de Fisiopatologia Renal LIM16, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo
- Postgraduate Program in Medicine, Nove de Julho University, São Paulo, SP, Brazil
| | - Rosa M A Moysés
- Laboratorio de Fisiopatologia Renal LIM16, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo
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23
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Alzahrani AMA, Al-Khattabi GH. Factors Affecting Adherence to Phosphate-binding Medications among Patients with End-stage Kidney Disease in Makkah City. Saudi J Kidney Dis Transpl 2022; 33:516-525. [PMID: 37929544 DOI: 10.4103/1319-2442.388186] [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: 11/07/2023] Open
Abstract
Despite the evidence that the management of hyperphosphatemia depends heavily on adherence to phosphate-binding (PB) medications, many dialysis patients are non-adherent. Therefore, factors associated with non-adherence to PB medications should be identified and eliminated. This study aimed to identify and highlight factors influencing adherence to PB medications among patients with end-stage kidney disease (ESKD). A cross-sectional survey was conducted in the hemodialysis centers of three major governmental hospitals in Makkah City, Saudi Arabia. The World Health Organization's five dimensions of adherence to medication (patient, socioeconomic, condition, therapy, and health system) were used to guide the analysis. A multivariable logistic regression analysis was used to determine factors influencing adherence to PB medications among patients with ESKD. Three hundred and fifty-eight patients submitted completed questionnaires and were included in this study; of them, 87.99% were adherent to PB medications. The factors sex, adherence to dietary restrictions, and duration on dialysis were found to be significantly and positively associated with adherence to PB medications, whereas the factors difficulty to take medications and difficulty to adhere to a large number of tablets had significant and negative associations with adherence to PB medications. Hyperphosphatemia is a cause for concern as it leads to several life-threatening complications. The results of the present study encourage to recruit representative samples and consider more factors, such as patients' attitudes toward medications and provider-level factors, to inform policy and/or programmatic interventions that increase adherence to PB medications among patients with ESKD.
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Affiliation(s)
- Ali Mohammed A Alzahrani
- Department of Health Services Management, College of Public Health and Health Informatics, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Ghanim H Al-Khattabi
- Department of Preventive Medicine and Public Health Executive, Ministry of Health, Makkah, Saudi Arabia
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24
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Jadav PR, Husain SA, Mohan S, Crew R. Non calcium phosphate binders - Is there any evidence of benefit. Curr Opin Nephrol Hypertens 2022; 31:288-296. [PMID: 35266882 DOI: 10.1097/mnh.0000000000000796] [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: 11/25/2022]
Abstract
PURPOSE OF REVIEW Low-level evidence and opinion-based clinical practice guidelines highlight the substantial uncertainty in the practice patterns of hyperphosphatemia management in patients with chronic kidney disease (CKD). This manuscript reviews the evidence for the choice of phosphate binders and its impact on clinical outcomes. RECENT FINDINGS Phosphate binders are among the most common medications prescribed for patients on dialysis. Clinical practice guidelines recommend lowering phosphate levels toward normal range and restricting calcium-based binders in all CKD patients. There is substantial gap in the evidence underlying these recommendations with lack of any placebo-controlled, randomized trials showing survival benefits for any class of phosphate-binders. Despite the lack of evidence for specific phosphate target or if lowering phosphate improves survival, use of phosphate binders has remained central strategy in approach to hyperphosphatemia. Use of binders has added to the cost and contributed significant pill burden. Restriction of calcium-based binders to avoid positive calcium balance and consequent vascular calcification risk has a physiological rationale and weight of observational studies. SUMMARY There is currently no conclusive evidence that definitively guides the choice of any specific binders for management of hyperphosphatemia in patients with CKD. Use of noncalcium-based binders has a theoretical advantage in restricting total calcium intake to decrease the risk of vascular calcification but no proven benefits for mortality.
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Affiliation(s)
- Paresh R Jadav
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY
| | - S Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY
- The Columbia University Renal Epidemiology (CURE) Group
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY
- The Columbia University Renal Epidemiology (CURE) Group
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Russell Crew
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY
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25
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Haase VH. The ins and outs of ferric citrate. Kidney Int 2022; 101:668-670. [PMID: 35314048 DOI: 10.1016/j.kint.2021.12.032] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/17/2021] [Accepted: 12/17/2021] [Indexed: 10/18/2022]
Abstract
Ferric citrate is used clinically for the treatment of hyperphosphatemia in patients with chronic kidney disease and is approved as an oral iron replacement product for patients with iron-deficiency anemia. In this issue of Kidney International, Hanudel and colleagues take advantage of genetic models with and without chronic kidney injury to demonstrate that the enteric absorption of iron delivered by ferric citrate is dependent on ferroportin expression and does not involve paracellular iron transport.
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Affiliation(s)
- Volker H Haase
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA; Section of Integrative Physiology, Department of Medical Cell Biology, Uppsala University, Uppsala, Sweden; Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
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Kutílek Š, Rondziková-Mlynarčíková E, Pečenková K, Pikner R, Šmída T, Sládková E, Honzík T, Kolářová H, Magner M. Transient Hyperphosphatasemia in a Child with Autism Spectrum Disorder. Acta Medica (Hradec Kralove) 2022; 65:41-43. [PMID: 35793509 DOI: 10.14712/18059694.2022.16] [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] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by deficits in social communication and the presence of restricted interests and repetitive behaviors. Transient hyperphosphatasemia of infancy and early childhood (THI) is a benign laboratory disorder characterized by transiently extremely elevated activity of serum alkaline phosphatase (S-ALP). CASE REPORT We present a 21-month-old girl with a right leg limp, most probably due to reactive arthritis after febrile viral infection, and deterioration of psychomotor development with concomitant transient elevation of S-ALP (61.74 μkat/L; normal 2.36-7.68 μkat/L). Normal values of serum creatinine, aspartate-aminotransferase, alanin-aminotransferase, calcium, phosphate, together with normal wrist X-ray ruled out rickets or other bone or hepatic cause of high S-ALP. The S-ALP gradually decreased within 3 months, thus fulfilling the THI criteria. Screening for inborn errors of metabolism was negative and meticulous neurologic, psychologic and psychiatric assessment pointed to the diagnosis of autism spectrum disorder (ASD). There was no causal relationship between THI and ASD, as high S-ALP was an accidental and transient finding within the routine laboratory assessment. However, when THI occurs in a child with an onset of a new disorder, or with a pre-existing bone or liver disease, it might seriously concern the physician. CONCLUSION Children with THI should be spared from extensive evaluations and unnecessary blood draws.
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Affiliation(s)
- Štěpán Kutílek
- Department of Pediatrics, Klatovy Hospital, Klatovy, Czech Republic.
| | | | - Kamila Pečenková
- Department of Pediatrics, Klatovy Hospital, Klatovy, Czech Republic
| | - Richard Pikner
- Department of Clinical Biochemistry, Klatovy Hospital, Klatovy, Czech Republic
| | - Tomáš Šmída
- General Pediatric Practitioner, Klatovy, Czech Republic
| | - Eva Sládková
- Department of Pediatrics, Faculty Hospital in Pilsen and Faculty of Medicine in Pilsen, Charles University, Czech Republic
| | - Tomáš Honzík
- Department of Pediatrics and Inherited Metabolic Disorders, Faculty Hospital in Prague and 1st Faculty of Medicine in Prague, Charles University, Czech Republic
| | - Hana Kolářová
- Department of Pediatrics and Inherited Metabolic Disorders, Faculty Hospital in Prague and 1st Faculty of Medicine in Prague, Charles University, Czech Republic
| | - Martin Magner
- Department of Pediatrics and Inherited Metabolic Disorders, Faculty Hospital in Prague and 1st Faculty of Medicine in Prague, Charles University, Czech Republic
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27
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Martínez-Arias L, Panizo-García S, Martín-Vírgala J, Martín-Carro B, Fernández-Villabrille S, Avello-Llano N, Miguel-Fernández D, Ruíz Torres MP, Cannata-Andía JB, Carrillo-López N, Naves-Díaz M. Contribution of phosphorus and PTH to the development of cardiac hypertrophy and fibrosis in an experimental model of chronic renal failure. Nefrologia 2021; 41:640-651. [PMID: 36165154 DOI: 10.1016/j.nefroe.2021.12.004] [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: 08/14/2020] [Revised: 02/01/2021] [Accepted: 02/07/2021] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Adequate serum phosphorus levels in patients with chronic kidney disease is essential for their clinical management. However, the control of hyperphosphatemia is difficult because is normally associated with increases in serum PTH. In the present study, the effects of hyperphosphatemia, in the presence of elevated and normal PTH, on cardiac inflammation, hypertrophy and fibrosis in an experimental renal failure model were analyzed. MATERIALS AND METHODS 4 groups of rats were formed. Two groups underwent total parathyroidectomy (PTx). Rats with Ca <7.5 mg/dL and PTH < 50 pg/mL underwent 7/8 nephrectomy (CRF) and a subcutaneous pellet was placed that releases PTH 1-34 (5 µg/kg/day). One group received a diet with normal P (NP) (CRF + PTx + rPTH + NP group) and another with a high P diet (0.9% - HP) (CRF + PTx + rPTH + HP group). Other 2 groups that only had CRF received NP (CRF + NP) and HP (CRF + HP) diet. A SHAM group for nephrectomy and parathyroidectomy was also added. After 14 weeks the rats were sacrificed. RESULTS The groups with a diet high in phosphorus (CRF + H A and CRF + PTx + rPTH + HP) had a significant reduction in creatinine clearance and also in body weight with an increase in serum phosphorus regardless of parathyroidectomy, but not serum levels of calcium, FGF23 and calcitriol that were 2-3 times higher in the group with secondary hyperparathyroidism (CRF + HP). The diameter of the cardiomyocytes was greater in the CRF + HP group, while parathyroidectomy (CRF + PTx + rPTH + HP) significantly reduced them, despite the high and similar serum phosphorus values. TNF-α, Adam17 and cardiac fibrosis at the histological and molecular level showed a similar pattern with increases in the group with severe secondary hyperparathyroidism (CRF + HP). CONCLUSIONS Hyperphosphatemia confirmed its importance in the genesis of secondary hyperparathyroidism, but also of kidney damage that was independent of PTH levels. However, inflammation, fibrosis, and cardiomyocyte growth were more closely related to PTH levels, since in the presence of similar severe hyperphosphatemia, parathyroidectomy reduced the values of inflammatory parameters, cardiac hypertrophy, and fibrosis.
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Affiliation(s)
- Laura Martínez-Arias
- Unidad de Gestión Clínica de Metabolismo Óseo, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Retic REDinREN-ISCIII, Universidad de Oviedo, Oviedo, Spain
| | - Sara Panizo-García
- Unidad de Gestión Clínica de Metabolismo Óseo, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Retic REDinREN-ISCIII, Universidad de Oviedo, Oviedo, Spain
| | - Julia Martín-Vírgala
- Unidad de Gestión Clínica de Metabolismo Óseo, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Retic REDinREN-ISCIII, Universidad de Oviedo, Oviedo, Spain
| | - Beatriz Martín-Carro
- Unidad de Gestión Clínica de Metabolismo Óseo, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Retic REDinREN-ISCIII, Universidad de Oviedo, Oviedo, Spain
| | - Sara Fernández-Villabrille
- Unidad de Gestión Clínica de Metabolismo Óseo, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Retic REDinREN-ISCIII, Universidad de Oviedo, Oviedo, Spain
| | - Noelia Avello-Llano
- Laboratorio de Medicina, Hospital Universitario Central de Asturias, Universidad de Oviedo, Oviedo, Spain
| | - Diego Miguel-Fernández
- Laboratorio de Medicina, Hospital Universitario Central de Asturias, Universidad de Oviedo, Oviedo, Spain
| | - María Piedad Ruíz Torres
- Departamento de Biología de Sistemas, Unidad de Fisiología, Facultad de Medicina, Universidad de Alcalá de Henares, Retic REDinREN-ISCIII, Madrid, Spain
| | - Jorge B Cannata-Andía
- Unidad de Gestión Clínica de Metabolismo Óseo, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Retic REDinREN-ISCIII, Universidad de Oviedo, Oviedo, Spain.
| | - Natalia Carrillo-López
- Unidad de Gestión Clínica de Metabolismo Óseo, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Retic REDinREN-ISCIII, Universidad de Oviedo, Oviedo, Spain
| | - Manuel Naves-Díaz
- Unidad de Gestión Clínica de Metabolismo Óseo, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Retic REDinREN-ISCIII, Universidad de Oviedo, Oviedo, Spain
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28
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Yee J, Rosenbaum D, Jacobs JW, Sprague SM. Small Intestinal Phosphate Absorption: Novel Therapeutic Implications. Am J Nephrol 2021; 52:522-530. [PMID: 34515051 DOI: 10.1159/000518110] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 06/24/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) affects approximately 15% of adults in the USA. As CKD progresses, urinary phosphate excretion decreases and results in phosphate retention and, eventually, hyperphosphatemia. As hyperphosphatemia is associated with numerous adverse outcomes, including increased cardiovascular mortality, reduction in phosphorus concentrations is a guideline-recommended, established clinical practice. Dietary phosphate restriction, dialysis, and phosphate binders are currently the only options for phosphate management. However, many patients with hyperphosphatemia have phosphorus concentrations >5.5 mg/dL, despite treatment. SUMMARY This review pre-sents recent advances in the understanding of intestinal phosphate absorption and therapeutic implications. Dietary phosphate is absorbed in the intestine through two distinct pathways, paracellular absorption and transcellular transport. Recent evidence indicates that the paracellular route accounts for 65-80% of total phosphate absorbed. Thus, the paracellular pathway is the dominant mechanism of phosphate absorption. Tenapanor is a first-in-class, non-phosphate binder that inhibits the sodium-hydrogen exchanger 3 or solute carrier family 9 member 3 (SLC9A3) encoded by the SLC9A3 gene, and blocks paracellular phosphate absorption. Key Messages: Targeted inhibition of sodium-hydrogen exchanger 3 effectively reduces paracellular permeability of phosphate. Novel therapies that target the paracellular pathway may improve phosphate control in chronic kidney disease.
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Affiliation(s)
- Jerry Yee
- Nephrology and Hypertension, Henry Ford Hospital, Detroit, Michigan, USA
| | | | | | - Stuart M Sprague
- Division of Nephrology and Hypertension, NorthShore University Health System, Evanston, Illinois, USA
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Affiliation(s)
- Shokoufeh Mousavi
- From the Clinical Research of Development Center, Shahid Beheshti Hospital, Qom University of Medical Sciences, Qom
| | - Maryam Masoumi
- From the Clinical Research of Development Center, Shahid Beheshti Hospital, Qom University of Medical Sciences, Qom
| | - Saeed Shakiba
- School of Medicine, Tehran University of Medical Science, Tehran, Iran
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30
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Yin J, Yin J, Lian R, Li P, Zheng J. Implementation and effectiveness of an intensive education program on phosphate control among hemodialysis patients: a non-randomized, single-arm, single-center trial. BMC Nephrol 2021; 22:243. [PMID: 34210293 PMCID: PMC8252215 DOI: 10.1186/s12882-021-02441-8] [Citation(s) in RCA: 2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 06/04/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Hyperphosphatemia is a common complication in patients on maintenance hemodialysis. Patients' adherence to phosphorus control can be improved by consistent education. However, few studies have focused on the model construction and effects of health education on phosphate control for hemodialysis patients. OBJECTIVE To develop an intensive education program focusing on phosphate control among hemodialysis patients and to analyze the effectiveness of this program. DESIGN A non-randomized, single-arm, single-center trial lasting for 6 months. SETTING This program was conducted in a hemodialysis center in a teaching hospital in Zhuhai, China. PARTICIPANTS Patients on maintenance hemodialysis with hyperphosphatemia. METHODS An intensive hyperphosphatemia control education program lasting for 6 months was conducted among 366 hemodialysis patients applying the First Principles of Instruction model, which focused on mastering four stages: (a) activation of prior experience, (b) demonstration of skills, (c) application of skills and (d) integration of these skills into real-world activities. The controlled percentage of serum phosphorus, knowledge of hyperphosphatemia, and adherence to phosphate binders before and after the education program were assessed. RESULTS The proportion of controlled serum phosphorus was significantly increased from 43.5 to 54.9% (P<0.001). The scores on the knowledge of phosphate control were improved significantly from 59.0 ± 18.9 to 80.6 ± 12.4 (P < 0.001). The proportion of high adherence to phosphate binders was increased dramatically from 21.9 to 44.5% (P < 0.001). CONCLUSION The intensive education program can effectively improve serum phosphorus, knowledge of hyperphosphatemia, and adherence to phosphate binders among hemodialysis patients. TRIAL REGISTRATION Chinese Clinical Trial Registry, ChiCTR2100042017 . Retrospectively registered January 12th, 2021.
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Affiliation(s)
- Jinmei Yin
- Blood purification center, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Jun Yin
- Blood purification center, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Rongli Lian
- Department of critical medicine, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Peiqiu Li
- Blood purification center, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Jing Zheng
- School of Nursing, Guangdong Pharmaceutical University, 283 Jianghai Avenue, Guangzhou, 510310 Guangdong Province China
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Shigematsu T, Une Y, Ikejiri K, Kanda H, Fukagawa M, Akizawa T. Therapeutic Effects of Add-On Tenapanor for Hemodialysis Patients with Refractory Hyperphosphatemia. Am J Nephrol 2021; 52:496-506. [PMID: 34098559 PMCID: PMC8491508 DOI: 10.1159/000516156] [Citation(s) in RCA: 7] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/25/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Phosphate binders are used to treat hyperphosphatemia. Some patients have inappropriately controlled serum phosphorus levels, which may occur for many reasons, including a high pill burden and adverse events (AEs). Tenapanor selectively inhibits the passive paracellular transfer of phosphate in the gastrointestinal tract, thereby reducing serum phosphorus levels. This novel mechanism of action may contribute to improved phosphate management. The efficacy and safety of tenapanor have not been evaluated in Japanese patients with high serum phosphorus levels despite treatment with phosphate binders. This study aimed to assess the efficacy and safety of add-on tenapanor therapy for reducing serum phosphorus levels in this population. METHODS This multicenter, double-blind, randomized, placebo-controlled trial enrolled patients with refractory hyperphosphatemia undergoing hemodialysis. Patients were randomly assigned in a 1:1 ratio to receive tenapanor or placebo as an add-on to their phosphate binder regimen for 6 weeks. Change in serum phosphorus levels at week 6 (day 43) compared with the baseline value (day 1, week 0) (primary endpoint), achievement of target serum phosphorus levels (serum phosphorus level ≤6.0 or ≤5.5 mg/dL), and safety, based on all AEs and drug-related AEs, were among the outcomes evaluated. RESULTS In total, 24 patients were randomly assigned to the placebo group and 23 to the tenapanor group. The mean serum phosphorus level decreased from 7.01 mg/dL on day 1 to 6.69 mg/dL on day 43 in the placebo group and from 6.77 mg/dL on day 1 to 4.67 mg/dL on day 43 in the tenapanor group. In the placebo and tenapanor groups (modified intent-to-treat population), the mean (standard deviation) change in the serum phosphorus level at day 43 (last observation carried forward [LOCF]) was 0.08 (1.52) mg/dL and -1.99 (1.24) mg/dL, respectively, with a between-group difference of -2.07 (95% confidence interval: -2.89, -1.26; p < 0.001). The target achievement rate (serum phosphorus level ≤6.0 mg/dL at week 6 [LOCF]) was 37.5 and 87.0% in the placebo and tenapanor groups, respectively. Diarrhea was the most common drug-related AE, and it occurred in 8.3 and 65.2% of patients in the placebo and tenapanor groups, respectively. No specific AEs were observed with add-on tenapanor or with phosphate binders. DISCUSSION/CONCLUSION Therapy with existing phosphate binders and add-on tenapanor resulted in a significant decrease in serum phosphorus level compared with the placebo group in patients with refractory hyperphosphatemia despite treatment with phosphate binders. No new safety signals were raised, and add-on tenapanor was generally well tolerated.
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Affiliation(s)
| | - Yotaro Une
- Research and Development Division, Kyowa Kirin Co., Ltd., Tokyo, Japan
| | - Kazuaki Ikejiri
- Research and Development Division, Kyowa Kirin Co., Ltd., Tokyo, Japan
| | - Hironori Kanda
- Research and Development Division, Kyowa Kirin Co., Ltd., Tokyo, Japan
| | - Masafumi Fukagawa
- Division of Nephrology, Department of Internal Medicine, Endocrinology, and Metabolism, Tokai University School of Medicine, Isehara, Japan
| | - Tadao Akizawa
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
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Chaiyakittisopon K, Pattanaprateep O, Ruenroengbun N, Sapankaew T, Ingsathit A, Mckay GJ, Attia J, Thakkinstian A. Evaluation of the cost-utility of phosphate binders as a treatment option for hyperphosphatemia in chronic kidney disease patients: a systematic review and meta-analysis of the economic evaluations. Eur J Health Econ 2021; 22:571-584. [PMID: 33677736 PMCID: PMC8166732 DOI: 10.1007/s10198-021-01275-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 08/21/2020] [Accepted: 02/18/2021] [Indexed: 05/06/2023]
Abstract
BACKGROUND Uncontrolled hyperphosphatemia in chronic kidney disease (CKD) patients commonly results in vascular calcification leading to increased risk of cardiovascular disease. Phosphate binders (PBs) are used for hyperphosphatemia and can be calcium-based (CBPBs) or non-calcium-based (NCBPBs), the latter being more expensive than CBPBs. In this study, we used meta-analysis approaches to assess the cost-utility of PBs for hyperphosphatemia in CKD patients. METHODS Relevant studies published prior to June 2019 were identified from PubMed, Scopus, the Cochrane Library, the National Health Service Economic Evaluation Database, and the Cost-Effectiveness Analysis Registry. Studies were eligible if they included CKD patients with hyperphosphatemia, compared any PBs and reported economic outcomes. Meta-analysis was applied to pool incremental net benefit (INB) across studies stratified by country income. RESULTS A total of 25 studies encompassing 32 comparisons were eligible. Lanthanum carbonate, a NCBPB, was a more cost-effective option than CBPBs in high-income countries (HICs), with a pooled INB of $3984.4 (599.5-7369.4), especially in pre-dialysis patients and used as a second-line option with INBs of $4860.2 (641.5-9078.8), $4011.0 (533.7-7488.3), respectively. Sevelamer, also a NCBPB, was not more cost-effective as a first-line option compared to CBPBs with a pooled INB of $6045.8 (- 23,453.0 to 35,522.6) and $34,168.9 (- 638.0 to 68,975.7) in HICs and upper middle-income countries, respectively. CONCLUSIONS Lanthanum carbonate was significantly more cost-effective than CBPBs as a second-line option for hyperphosphatemia in pre-dialysis patients in HICs. However, the use of sevelamer is not more cost-effective as a first-line option compared to CBPBs.
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Affiliation(s)
- Kamolpat Chaiyakittisopon
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 3rd Floor, Research Center Building, 270 RAMA VI Road. Ratchathewi, Bangkok, 10400, Thailand
- Department of Community Pharmacy, Faculty of Pharmacy, Silpakorn University, Nakhon Pathom, Thailand
| | - Oraluck Pattanaprateep
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 3rd Floor, Research Center Building, 270 RAMA VI Road. Ratchathewi, Bangkok, 10400, Thailand.
| | - Narisa Ruenroengbun
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 3rd Floor, Research Center Building, 270 RAMA VI Road. Ratchathewi, Bangkok, 10400, Thailand
- Department of Pharmacy, Faculty of Pharmacy, Silpakorn University, Nakhon Pathom, Thailand
| | - Tunlanut Sapankaew
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 3rd Floor, Research Center Building, 270 RAMA VI Road. Ratchathewi, Bangkok, 10400, Thailand
| | - Atiporn Ingsathit
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 3rd Floor, Research Center Building, 270 RAMA VI Road. Ratchathewi, Bangkok, 10400, Thailand
| | - Gareth J Mckay
- Center for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - John Attia
- Centre for Clinical Epidemiology and Biostatistics, School of Medicine and Public Health, Hunter Medical Research Institute, University of Newcastle, New Lambton, NSW, Australia
| | - Ammarin Thakkinstian
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 3rd Floor, Research Center Building, 270 RAMA VI Road. Ratchathewi, Bangkok, 10400, Thailand
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Ogata H, Fukagawa M, Hirakata H, Kagimura T, Fukushima M, Akizawa T. Effect of Treating Hyperphosphatemia With Lanthanum Carbonate vs Calcium Carbonate on Cardiovascular Events in Patients With Chronic Kidney Disease Undergoing Hemodialysis: The LANDMARK Randomized Clinical Trial. JAMA 2021; 325:1946-1954. [PMID: 34003226 PMCID: PMC8132143 DOI: 10.1001/jama.2021.4807] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 03/12/2021] [Indexed: 11/14/2022]
Abstract
Importance Among patients with hyperphosphatemia undergoing dialysis, it is unclear whether non-calcium-based phosphate binders are more effective than calcium-based binders for reducing cardiovascular events. Objective To determine whether lanthanum carbonate reduces cardiovascular events compared with calcium carbonate in patients with hyperphosphatemia at risk of vascular calcification undergoing hemodialysis. Design, Setting, and Participants Open-label, randomized, parallel-group clinical trial with blinded end point adjudication performed in 2374 patients with chronic kidney disease from 273 hemodialysis facilities in Japan. Eligible patients had hyperphosphatemia and 1 or more risk factors for vascular calcification (ie, ≥65 years, postmenopausal, diabetes). Enrollment occurred from November 2011 to July 2014; follow-up ended June 2018. Interventions Patients were randomized to receive either lanthanum carbonate (n = 1154) or calcium carbonate (n = 1155) and titrated to achieve serum phosphate levels of between 3.5 mg/dL and 6.0 mg/dL. Main Outcomes and Measures The primary outcome was a composite cardiovascular event (cardiovascular death, nonfatal myocardial infarction or stroke, unstable angina, transient ischemic attack, or hospitalization for heart failure or ventricular arrhythmia). Secondary outcomes included overall survival, secondary hyperparathyroidism-free survival, hip fracture-free survival, and adverse events. Results Among 2309 randomized patients (median age, 69 years; 40.5% women), 1851 (80.2%) completed the trial. After a median follow-up of 3.16 years, cardiovascular events occurred in 147 of 1063 patients in the lanthanum calcium group and 134 of 1072 patients in the calcium carbonate group (incidence rate, 4.80 vs 4.30 per 100 person-years; difference 0.50 per 100 person-years [95% CI, -0.57 to 1.56]; hazard ratio [HR], 1.11 [95%, CI, 0.88 to 1.41], P = .37). There were no significant differences in all-cause death (difference, 0.43 per 100 person-years [95% CI, -0.63 to 1.49]; HR, 1.10 [95% CI, 0.88 to 1.37]; P = .42) or hip fracture (difference, 0.10 per 100 person-years [95% CI, -0.26 to 0.47]; HR, 1.21 [95% CI, 0.62 to 2.35]; P = .58). The lanthanum carbonate group had an increased risk of cardiovascular death (difference, 0.61 per 100 person-years [95% CI, 0.02 to 1.21]; HR, 1.51 [95% CI, 1.01 to 2.27]; P = .045) and secondary hyperparathyroidism (difference, 1.34 [95% CI, 0.49 to 2.19]; HR, 1.62 [95% CI, 1.19 to 2.20]; P = .002). Adverse events occurred in 282 (25.7%) in the lanthanum carbonate group and 259 (23.4%) in the calcium carbonate groups. Conclusions and Relevance Among patients undergoing hemodialysis with hyperphosphatemia and at least 1 vascular calcification risk factor, treatment of hyperphosphatemia with lanthanum carbonate compared with calcium carbonate did not result in a significant difference in composite cardiovascular events. However, the event rate was low, and the findings may not apply to patients at higher risk. Trial Registration ClinicalTrials.gov Identifier: NCT01578200; UMIN Clinical Trial Registry Identifier: UMIN000006815.
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Affiliation(s)
- Hiroaki Ogata
- Division of Nephrology, Department of Internal Medicine, Showa University Northern Yokohama Hospital, Tsuzuki, Yokohama, Kanagawa, Japan
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | | | - Tatsuo Kagimura
- The Translational Research Center for Medical Innovation, Foundation for Biomedical Research and Innovation at Kobe, Chuo-ku, Kobe, Hyogo, Japan
| | - Masanori Fukushima
- The Translational Research Center for Medical Innovation, Foundation for Biomedical Research and Innovation at Kobe, Chuo-ku, Kobe, Hyogo, Japan
| | - Tadao Akizawa
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Shinagawa, Tokyo, Japan
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Affiliation(s)
- Yoko Narasaki
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California, Irvine, Orange, California
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Abstract
ABSTRACT Tumor lysis syndrome (TLS) is one of the most common oncologic emergencies, occurring when tumor cell contents are rapidly released into the bloodstream. This release of cellular contents, including uric acid, phosphate, and potassium, can rapidly overwhelm the body's homeostasis mechanisms, leading to renal failure, seizures, cardiac dysrhythmias, or death. With an estimated 1.8 million new diagnoses of cancer projected in 2020 and an increase in the use of targeted agents for treatment, healthcare providers must be able to recognize, diagnose, and manage patients presenting with TLS.
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Affiliation(s)
- Chloe Greguska
- Chloe Greguska practices on the inpatient malignant hematology team at Levine Cancer Institute in Charlotte, N.C. The author has disclosed no potential conflicts of interest, financial or otherwise
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Scialla JJ, Kendrick J, Uribarri J, Kovesdy CP, Gutiérrez OM, Jimenez EY, Kramer HJ. State-of-the-Art Management of Hyperphosphatemia in Patients With CKD: An NKF-KDOQI Controversies Perspective. Am J Kidney Dis 2021; 77:132-141. [PMID: 32771650 PMCID: PMC8109252 DOI: 10.1053/j.ajkd.2020.05.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [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: 11/22/2019] [Accepted: 05/16/2020] [Indexed: 02/07/2023]
Abstract
Phosphate binders are among the most common medications prescribed to patients with kidney failure receiving dialysis and are often used in advanced chronic kidney disease (CKD). In patients with CKD glomerular filtration rate category 3a (G3a) or worse, including those with kidney failure who are receiving dialysis, clinical practice guidelines suggest "lowering elevated phosphate levels towards the normal range" with possible strategies including dietary phosphate restriction or use of binders. Additionally, guidelines suggest restricting the use of oral elemental calcium often contained in phosphate binders. Nutrition guidelines in CKD suggest<800-1,000mg of calcium daily, whereas CKD bone and mineral disorder guidelines do not provide clear targets, but<1,500mg in maintenance dialysis patients has been previously recommended. Many different classes of phosphate binders are now available and clinical trials have not definitively demonstrated the superiority of any class of phosphate binders over another with regard to clinical outcomes. Use of phosphate binders contributes substantially to patients' pill burden and out-of-pocket costs, and many have side effects. This has led to uncertainty regarding the use and best choice of phosphate binders for patients with CKD or kidney failure. In this controversies perspective, we discuss the evidence base around binder use in CKD and kidney failure with a focus on comparisons of available binders.
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Affiliation(s)
- Julia J Scialla
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA; Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA.
| | - Jessica Kendrick
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Jaime Uribarri
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Csaba P Kovesdy
- Department of Medicine, University of Tennessee Health Science Center and Memphis Veterans Affairs Medical Center, Memphis, TN
| | - Orlando M Gutiérrez
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL; Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL
| | - Elizabeth Yakes Jimenez
- Department of Pediatrics, University of New Mexico, Albuquerque, New Mexico; Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico; Nutrition Research Network, Academy of Nutrition and Dietetics, Chicago, IL
| | - Holly J Kramer
- Department of Medicine, Loyola University Chicago, Maywood, IL; Department of Public Health Sciences, Loyola University Chicago, Maywood, IL
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Toussaint ND, Pedagogos E, Lioufas NM, Elder GJ, Pascoe EM, Badve SV, Valks A, Block GA, Boudville N, Cameron JD, Campbell KL, Chen SSM, Faull RJ, Holt SG, Jackson D, Jardine MJ, Johnson DW, Kerr PG, Lau KK, Hooi LS, Narayan O, Perkovic V, Polkinghorne KR, Pollock CA, Reidlinger D, Robison L, Smith ER, Walker RJ, Wang AYM, Hawley CM. A Randomized Trial on the Effect of Phosphate Reduction on Vascular End Points in CKD (IMPROVE-CKD). J Am Soc Nephrol 2020; 31:2653-2666. [PMID: 32917784 PMCID: PMC7608977 DOI: 10.1681/asn.2020040411] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [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: 04/05/2020] [Accepted: 07/14/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Hyperphosphatemia is associated with increased fibroblast growth factor 23 (FGF23), arterial calcification, and cardiovascular mortality. Effects of phosphate-lowering medication on vascular calcification and arterial stiffness in CKD remain uncertain. METHODS To assess the effects of non-calcium-based phosphate binders on intermediate cardiovascular markers, we conducted a multicenter, double-blind trial, randomizing 278 participants with stage 3b or 4 CKD and serum phosphate >1.00 mmol/L (3.10 mg/dl) to 500 mg lanthanum carbonate or matched placebo thrice daily for 96 weeks. We analyzed the primary outcome, carotid-femoral pulse wave velocity, using a linear mixed effects model for repeated measures. Secondary outcomes included abdominal aortic calcification and serum and urine markers of mineral metabolism. RESULTS A total of 138 participants received lanthanum and 140 received placebo (mean age 63.1 years; 69% male, 64% White). Mean eGFR was 26.6 ml/min per 1.73 m2; 45% of participants had diabetes and 32% had cardiovascular disease. Mean serum phosphate was 1.25 mmol/L (3.87 mg/dl), mean pulse wave velocity was 10.8 m/s, and 81.3% had abdominal aortic calcification at baseline. At 96 weeks, pulse wave velocity did not differ significantly between groups, nor did abdominal aortic calcification, serum phosphate, parathyroid hormone, FGF23, and 24-hour urinary phosphate. Serious adverse events occurred in 63 (46%) participants prescribed lanthanum and 66 (47%) prescribed placebo. Although recruitment to target was not achieved, additional analysis suggested this was unlikely to have significantly affected the principle findings. CONCLUSIONS In patients with stage 3b/4 CKD, treatment with lanthanum over 96 weeks did not affect arterial stiffness or aortic calcification compared with placebo. These findings do not support the role of intestinal phosphate binders to reduce cardiovascular risk in patients with CKD who have normophosphatemia. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Australian Clinical Trials Registry, ACTRN12610000650099.
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Affiliation(s)
- Nigel D Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, The Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Eugenia Pedagogos
- Department of Medicine, The Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
- Alfred Health, Melbourne, Victoria, Australia
- Western Health, Melbourne, Victoria, Australia
| | - Nicole M Lioufas
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, The Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
- Western Health, Melbourne, Victoria, Australia
| | - Grahame J Elder
- School of Medicine, University of Notre Dame, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Osteoporosis and Bone Biology Division, Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
| | - Elaine M Pascoe
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Queensland, Australia
| | - Sunil V Badve
- St. George Hospital, Sydney, New South Wales, Australia
- Renal and Metabolic Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Andrea Valks
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Queensland, Australia
| | | | - Neil Boudville
- Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - James D Cameron
- Monash Cardiovascular Research Centre, Monash Heart, Monash Health, Clayton, Victoria, Australia
- Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Katrina L Campbell
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | | | - Randall J Faull
- Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia
- Central Northern Adelaide Renal and Transplantation Services, Adelaide, South Australia, Australia
| | - Stephen G Holt
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, The Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | | | - Meg J Jardine
- Concord Repatriation and General Hospital, Concord, New South Wales, Australia
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - David W Johnson
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Queensland, Australia
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Translational Research Institute, Brisbane, Queensland, Australia
| | - Peter G Kerr
- Department of Medicine, Monash University, Clayton, Victoria, Australia
- Monash Health, Clayton, Victoria, Australia
| | - Kenneth K Lau
- Department of Medicine, Monash University, Clayton, Victoria, Australia
- Monash Health, Clayton, Victoria, Australia
| | | | - Om Narayan
- Monash Cardiovascular Research Centre, Monash Heart, Monash Health, Clayton, Victoria, Australia
- Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Vlado Perkovic
- Renal and Metabolic Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Kevan R Polkinghorne
- Department of Medicine, Monash University, Clayton, Victoria, Australia
- Monash Health, Clayton, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Carol A Pollock
- Kolling Institute, Royal North Shore Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Donna Reidlinger
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Queensland, Australia
| | - Laura Robison
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Queensland, Australia
| | - Edward R Smith
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, The Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Robert J Walker
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | | | - Carmel M Hawley
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Queensland, Australia
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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Palafox-Serdán F, Luna-Montiel OA, Pablo-Franco SE, Guillen-Tejada DL, Carreño-Vázquez SD, Silva Pereira TS, Islas Romero LM, Villaseñor López K, Ortega-Régules AE, Jiménez-Garduño AM. Nutritional Guideline for the Management of Mexican Patients with CKD and Hyperphosphatemia. Nutrients 2020; 12:E3289. [PMID: 33121062 PMCID: PMC7693767 DOI: 10.3390/nu12113289] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 10/19/2020] [Accepted: 10/21/2020] [Indexed: 12/31/2022] Open
Abstract
Chronic kidney disease (CKD) represents a serious concern for the Mexican population since the main predisposing diseases (diabetes, hypertension, etc.) have a high prevalence in the country. The development of frequent comorbidities during CKD such as anemia, metabolic disorders, and hyperphosphatemia increases the costs, symptoms, and death risks of the patients. Hyperphosphatemia is likely the only CKD comorbidity in which pharmaceutical options are restricted to phosphate binders and where nutritional management seems to play an important role for the improvement of biochemical and clinical parameters. Nutritional interventions aiming to control serum phosphate levels need to be based on food tables, which should be specifically elaborated for the cultural context of each population. Until now, there are no available food charts compiling a high amount of Mexican foods and describing phosphorus content as well as the phosphate to protein ratio for nutritional management of hyperphosphatemia in CKD. In this work, we elaborate a highly complete food chart as a reference for Mexican clinicians and include charts of additives and drug phosphate contents to consider extra sources of inorganic phosphate intake. We aim to provide an easy guideline to contribute to the implementation of more nutritional interventions focusing on this population in the country.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Aura M. Jiménez-Garduño
- Health Sciences Department, Universidad de las Américas Puebla, UDLAP, Ex Hacienda Sta. Catarina Mártir S/N. Puebla, C.P. San Andrés Cholula 72810, Mexico; (F.P.-S.); (O.A.L.-M.); (S.E.P.-F.); (D.L.G.-T.); (S.D.C.-V.); (T.S.S.P.); (L.M.I.R.); (K.V.L.); (A.E.O.-R.)
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Aleidi AM, Alayed NJ, Alduraibi HM, Alqassimi NS, Ismail AA. Phosphate binders usage, patients knowledge, and adherence. A cross-sectional study in 4 centers at Qassim, Saudi Arabia. Saudi Med J 2020; 41:1076-1082. [PMID: 33026048 PMCID: PMC7841503 DOI: 10.15537/smj.2020.10.25381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To assess phosphate binders' usage, knowledge regarding their utilization, and adherence among hemodialysis patients in Qassim, Saudi Arabia. METHODS A prospective cross-sectional study conducted at 4 dialysis centers in Qassim, Saudi Arabia with inclusion of 237 patients' undergoing hemodialysis between November 2018 to January 2019. The study involved interviewing the patients, reviewing their medical records for biomarkers used to assess kidney function, and assessing the patients' knowledge-based regarding dietary phosphate control, as well as adherence to phosphate binders' usage. Results: Out of 237 included patients, male to female ratio was 54:46. The prevalence of prescribing non- calcium phosphate binders was 82.7% whereas prescribing calcium phosphate binders was 73.8%. A total of 63% of patients showed a medium level of adherence to phosphate binders. Although adherence level was not poor, therapeutic eficacy was affected by other factors such as administration time adherence positively correlated with the serum phosphate level (p=0.00). CONCLUSION Phosphate binders usage is frequent among hemodialysis patients in Qassim centers. Circulating phosphate level was affected by the extent of patients' knowledge of dietary control and adherence to the usage of phosphate binders. Thus, we recommend enhancing patient education in reference to high- and low- phosphate-rich diet to take wise dietary decisions, lower pill burden, and improve adherence toward the control of hyperphosphatemia.
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Affiliation(s)
- Alanoud M Aleidi
- College of Pharmacy, Qassim University, Qassim, Kingdom of Saudi Arabia. E-mail.
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Mahjoubi F, Ghadir M, Samanian S, Heydari I, Honardoost M. Hyperphosphatemic familial tumoral calcinosis caused by a novel variant in the GALNT3 gene. J Endocrinol Invest 2020; 43:1125-1130. [PMID: 32125652 DOI: 10.1007/s40618-020-01203-x] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 02/19/2020] [Indexed: 10/24/2022]
Abstract
AIM Hyperphosphatemic familial tumoral calcinosis (HFTC) is a rare endocrine disorder caused by autosomal recessive variants in GALNT3, FGF23, and KL leading to progressive calcification of soft tissues and subsequent clinical effects. The aim of this was to study the cause of HFTC in an Iranian family. PATIENTS AND METHODS Four generations of a family with HFTC were studied for understanding the genetic pattern of the disease. Whole exome sequencing was applied on genomic DNA of the proband. Based on its result, genetically altered sequences were checked in his family through sanger sequencing. Then bioinformatics approaches as well as co-segregation analysis were applied to validate the genetic alteration. RESULTS A novel homozygous variant in exon four of GALNT3, namely p.R261Q was found. The parents and sister were carriers. CONCLUSION To our knowledge, it is the first-reported Iranian family with GALNT3-CDG novel variant.
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Affiliation(s)
- F Mahjoubi
- Genetic Foundation of Tehran, Solaleh Diagnostic Laboratory, Tehran, Iran
- Department of Clinical Genetics, Institute of Medical Biotechnology, National Institute of Genetic Engineering and Biotechnology (NIGEB), Tehran, Iran
| | - M Ghadir
- Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, No 10, Firoozeh St, Vali-asr Sq, Tehran, Iran
| | - S Samanian
- Genetic Foundation of Tehran, Solaleh Diagnostic Laboratory, Tehran, Iran
| | - I Heydari
- Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, No 10, Firoozeh St, Vali-asr Sq, Tehran, Iran
| | - M Honardoost
- Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, No 10, Firoozeh St, Vali-asr Sq, Tehran, Iran.
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Kilbane MT, Crowley RK, Twomey PJ, Maher C, McKenna MJ. Anorexia Nervosa with Markedly High Bone Turnover and Hyperphosphatemia During Refeeding Rectified by Denosumab. Osteoporos Int 2020; 31:1395-1398. [PMID: 31975181 DOI: 10.1007/s00198-020-05307-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 01/17/2020] [Indexed: 01/12/2023]
Abstract
We describe a unique case of hyperphosphatemia associated with a very high bone turnover rate in a 51-year-old postmenopausal woman with undiagnosed anorexia nervosa (AN) who presented with a low-trauma hip fracture. In view of her severely malnourished state, she was not fit for surgery. She was treated according to a refeeding protocol that mandated bed rest. Contrary to expectation, she developed sustained hyperphosphatemia and borderline hypercalcemia. Bone remodelling markers, both resorption and formation, were markedly elevated. Parathyroid hormone (PTH) was low-normal at 1.7 pmol/L, C-terminal fibroblast growth factor 23 (FGF23) was high at 293 RU/ml, but tubular maximum reabsorption of phosphate (TmPO4/GFR) was elevated at 1.93 mmol/L. Denosumab 60 mg was administered that was followed by: rapid normalisation of serum phosphate; normalisation of resorption markers, transient hypocalcaemia with secondary hyperparathyroidism, and normalisation of both TmPO4/GFR and C-terminal FGF23. We speculate that prolonged immobilization as part of AN management led to a high remodelling state followed by hyperphosphatemia and high-normal calcium with appropriate suppression of PTH and that marked hyperphosphatemia and high TmP/GFR despite high FGF23 indicates the necessity of PTH adequacy for excess FGF23 to lower TmP/GFR.
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Affiliation(s)
- M T Kilbane
- Department of Clinical Chemistry, St. Vincent's University Hospital, Dublin, Ireland.
| | - R K Crowley
- Department of Endocrinology, St. Vincent's University Hospital, Dublin, Ireland
- UCD School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - P J Twomey
- Department of Clinical Chemistry, St. Vincent's University Hospital, Dublin, Ireland
- UCD School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - C Maher
- Department of Psychiatry, St Vincent's University Hospital, Dublin, Ireland
| | - M J McKenna
- Department of Clinical Chemistry, St. Vincent's University Hospital, Dublin, Ireland
- Department of Endocrinology, St. Vincent's University Hospital, Dublin, Ireland
- UCD School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
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42
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Haffner D, Leifheit-Nestler M. Treatment of hyperphosphatemia: the dangers of aiming for normal PTH levels. Pediatr Nephrol 2020; 35:485-491. [PMID: 31823044 DOI: 10.1007/s00467-019-04399-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 09/30/2019] [Accepted: 10/14/2019] [Indexed: 12/14/2022]
Abstract
Secondary hyperparathyroidism is part of the complex of chronic kidney disease-associated mineral and bone disorders (CKD-MBD) and is linked with high bone turnover, ectopic calcification, and increased cardiovascular mortality. Therefore, measures for CKD-MBD aim at lowering PTH levels, but there is no general consensus on optimal PTH target values. This manuscript is part of a pros and cons debate for keeping PTH levels within the normal range in children with CKD, focusing on the cons. We conclude that a modest increase in PTH most likely represents an appropriate adaptive response to declining kidney function in patients with CKD stages 2-5D, due to phosphaturic effects and increasing bone resistance. There is no evidence for strictly keeping PTH levels within the normal range in CKD patients with respect to bone health and cardiovascular outcome. In addition, the potentially adverse effects of PTH-lowering measures, such as active vitamin D and calcimimetics, must be taken into account. We suggest that PTH values of 1-2 times the upper normal limit (ULN) may be acceptable in children with CKD stage 2-3, and that PTH levels of 1.7-5 times UNL may be optimal in patients with CKD stage 4-5D. However, standard care of CKD-MBD in children relies on a combination of different measures in which the observation of PTH levels is only a small part of, and trends in PTH levels rather than absolute target values should determine treatment decisions in patients with CKD as recommended by the 2017 KDIGO guidelines.
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Affiliation(s)
- Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Maren Leifheit-Nestler
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
- Pediatric Research Center, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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McAlister L, Pugh P, Greenbaum L, Haffner D, Rees L, Anderson C, Desloovere A, Nelms C, Oosterveld M, Paglialonga F, Polderman N, Qizalbash L, Renken-Terhaerdt J, Tuokkola J, Warady B, Walle JV, Shaw V, Shroff R. The dietary management of calcium and phosphate in children with CKD stages 2-5 and on dialysis-clinical practice recommendation from the Pediatric Renal Nutrition Taskforce. Pediatr Nephrol 2020; 35:501-518. [PMID: 31667620 PMCID: PMC6969014 DOI: 10.1007/s00467-019-04370-z] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/01/2019] [Accepted: 09/17/2019] [Indexed: 12/19/2022]
Abstract
In children with chronic kidney disease (CKD), optimal control of bone and mineral homeostasis is essential, not only for the prevention of debilitating skeletal complications and achieving adequate growth but also for preventing vascular calcification and cardiovascular disease. Complications of mineral bone disease (MBD) are common and contribute to the high morbidity and mortality seen in children with CKD. Although several studies describe the prevalence of abnormal calcium, phosphate, parathyroid hormone, and vitamin D levels as well as associated clinical and radiological complications and their medical management, little is known about the dietary requirements and management of calcium (Ca) and phosphate (P) in children with CKD. The Pediatric Renal Nutrition Taskforce (PRNT) is an international team of pediatric renal dietitians and pediatric nephrologists, who develop clinical practice recommendations (CPRs) for the nutritional management of various aspects of renal disease management in children. We present CPRs for the dietary intake of Ca and P in children with CKD stages 2-5 and on dialysis (CKD2-5D), describing the common Ca- and P-containing foods, the assessment of dietary Ca and P intake, requirements for Ca and P in healthy children and necessary modifications for children with CKD2-5D, and dietary management of hypo- and hypercalcemia and hyperphosphatemia. The statements have been graded, and statements with a low grade or those that are opinion-based must be carefully considered and adapted to individual patient needs based on the clinical judgment of the treating physician and dietitian. These CPRs will be regularly audited and updated by the PRNT.
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Affiliation(s)
- Louise McAlister
- Great Ormond Street Hospital for Children NHS Foundation Trust, and University College London, Institute of Child Health, WC1N 3JH, London, UK
| | - Pearl Pugh
- Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Dieter Haffner
- Children's Hospital, Hannover Medical School, Hannover, Germany
| | - Lesley Rees
- Great Ormond Street Hospital for Children NHS Foundation Trust, and University College London, Institute of Child Health, WC1N 3JH, London, UK
| | - Caroline Anderson
- Southampton Children's Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | | | - Michiel Oosterveld
- Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Fabio Paglialonga
- Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | | | - José Renken-Terhaerdt
- Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jetta Tuokkola
- Children's Hospital and Clinical Nutrition Unit, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | | | - Vanessa Shaw
- Great Ormond Street Hospital for Children NHS Foundation Trust, and University College London, Institute of Child Health, WC1N 3JH, London, UK
- University of Plymouth and University College London Institute of Child Health, London, UK
| | - Rukshana Shroff
- Great Ormond Street Hospital for Children NHS Foundation Trust, and University College London, Institute of Child Health, WC1N 3JH, London, UK.
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Tambaro FP, Wierda WG. Tumour lysis syndrome in patients with chronic lymphocytic leukaemia treated with BCL-2 inhibitors: risk factors, prophylaxis, and treatment recommendations. Lancet Haematol 2020; 7:e168-e176. [PMID: 32004486 DOI: 10.1016/s2352-3026(19)30253-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 11/17/2019] [Accepted: 11/21/2019] [Indexed: 01/23/2023]
Abstract
Tumour lysis syndrome is a complication of chemotherapy for haematological malignancies; in particular, aggressive leukaemias and lymphomas. For haematological malignancies, targeted therapies, such as small molecule inhibitors and monoclonal antibodies, have a high anti-tumour activity, are well tolerated, and have a low incidence of associated tumour lysis syndrome. The BCL-2 inhibitor venetoclax has a high anti-tumour activity in chronic lymphocytic leukaemia, achieving deep remissions by potently inducing apoptosis and increasing the risk for tumour lysis syndrome. In this Viewpoint, we discuss the pathophysiology, risk factors, monitoring, changes in laboratory parameters, and clinical manifestations of tumour lysis syndrome, and the prophylaxis and treatments available for this complication. Prophylaxis and treatment strategies have been implemented as standard of care in patients receiving venetoclax to minimise the risk of both laboratory and clinical manifestations of tumour lysis syndrome.
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MESH Headings
- Acute Kidney Injury/etiology
- Acute Kidney Injury/therapy
- Allopurinol/therapeutic use
- Antineoplastic Agents/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Arrhythmias, Cardiac/drug therapy
- Arrhythmias, Cardiac/etiology
- Bridged Bicyclo Compounds, Heterocyclic/adverse effects
- Bridged Bicyclo Compounds, Heterocyclic/therapeutic use
- Drug Synergism
- Humans
- Hyperphosphatemia/etiology
- Hyperphosphatemia/therapy
- Hyperuricemia/drug therapy
- Hyperuricemia/etiology
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/enzymology
- Molecular Targeted Therapy/adverse effects
- Neoplasm Proteins/antagonists & inhibitors
- Protein Kinase Inhibitors/adverse effects
- Proto-Oncogene Proteins c-bcl-2/antagonists & inhibitors
- Renal Dialysis
- Risk Factors
- Severity of Illness Index
- Sulfonamides/adverse effects
- Sulfonamides/therapeutic use
- Tumor Lysis Syndrome/diagnosis
- Tumor Lysis Syndrome/drug therapy
- Tumor Lysis Syndrome/etiology
- Tumor Lysis Syndrome/prevention & control
- Urate Oxidase/therapeutic use
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Affiliation(s)
- Francesco Paolo Tambaro
- Dipartimento di Oncoematologia-Unità di trapianto di midollo osseo, UT MD Anderson Cancer Center, Houston, TX, USA; Azienda Ospedaliera di Rilievo Nazionale Santobono-Pausilipon, Napoli, Italy
| | - William G Wierda
- Department of Leukemia, UT MD Anderson Cancer Center, Houston, TX, USA.
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Salhab N, Alrukhaimi M, Kooman J, Fiaccadori E, Aljubori H, Rizk R, Karavetian M. Effect of Intradialytic Exercise on Hyperphosphatemia and Malnutrition. Nutrients 2019; 11:nu11102464. [PMID: 31618888 PMCID: PMC6836201 DOI: 10.3390/nu11102464] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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: 09/18/2019] [Revised: 10/03/2019] [Accepted: 10/12/2019] [Indexed: 12/16/2022] Open
Abstract
Intradialytic exercise (IDE) is not routinely prescribed in hemodialysis (HD) units despite its potential benefits on patients' outcomes. This study was the first in the United Arab Emirates to examine the effect of aerobic IDE on hyperphosphatemia, malnutrition, and other health outcomes among HD patients. Participants were chosen from the largest HD unit in Sharjah Emirate for a quasi-experimental intervention with pre and post evaluation. The study lasted for 12 months. Study parameters were collected at baseline, post intervention, and follow-up. The intervention included a moderate-intensity aerobic IDE of 45 min per HD session; intensity was assessed using the Borg Scale. Patients were educated on the importance of exercise. Study outcomes were serum phosphorus (P), malnutrition inflammation score (MIS), quality of life (QOL), and pertinent blood tests. Forty-one eligible consenting HD patients were included in the study. Results at follow-up showed a non-significant reduction in P (p = 0.06) in patients who were hyperphosphatemic at baseline, but not in the sample as whole. MIS did not deteriorate throughout the study (p = 0.97). IDE resulted in a non-significant increase in the QOL visual analogue scale (p = 0.34). To conclude, aerobic IDE for 45 min is safe and could be beneficial, especially for hyperphosphatemic patients.
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Affiliation(s)
- Nada Salhab
- School of Nutrition and Translational Research in Metabolism, Faculty of Health Medicine and Life Sciences, Maastricht University, 6200 MD Maastricht, The Netherlands.
| | - Mona Alrukhaimi
- Department of Medicine, Dubai Medical College, P.O. Box 22331, Dubai, UAE.
| | - Jeroen Kooman
- Department of Internal Medicine, Division of Nephrology, University Hospital Maastricht, 6202 AZ Maastricht, The Netherlands.
| | - Enrico Fiaccadori
- Medicine and Surgery Department, Parma University Medical School, Via Gramsci 14, 43100 Parma, Italy.
| | - Harith Aljubori
- Department of Nephrology, Al Qassimi Hospital, P.O. Box 3500, Sharjah, UAE.
| | - Rana Rizk
- Institut National de Santé Publique, d'Épidémiologie Clinique et de Toxicologie, (INSPECT-LB) Beirut, Lebanon and Maastricht University, Faculty of Health Medicine and Life Sciences, 6200 MD Maastricht, The Netherlands.
| | - Mirey Karavetian
- Department of Health Sciences, College of Natural Health Sciences, Zayed University, P.O. Box 19282, Dubai, UAE.
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Abstract
Secondary hyperparathyroidism is a frequent complication of chronic kidney disease that begins early in the course of renal insufficiency as an adaptive response to maintain mineral homeostasis. This complex disorder affects the bone, leading to an increase in fracture risk and is associated with increased risks of vascular calcification and mortality. PURPOSE OF REVIEW: In this review, we examine the different strategies available to manage secondary hyperparathyroidism. Particularly, we focus on the adequate control of serum phosphorus by restricting intake and the use of phosphate binders, correction of hypocalcemia while minimizing calcium burden, and reduction in PTH levels through the use of vitamin D sterols and calcimimetics. RECENT FINDINGS: It was observed that although numerous agents directed at the correction of these abnormalities have demonstrated effectiveness on biochemical markers, there is still a relative scarcity of studies demonstrating treatment effectiveness as measured by hard clinical outcomes. In addition, most agents have side effects that may limit their use, even in patients in which the treatment has demonstrated efficacy in controlling these parameters. There is still controversy as to what therapeutic regimens to choose for a particular patient and what parameter should be used to follow their effects, including outcomes, side effects, pill burden, and costs, among others. In the present article, we analyze controversial aspects of the different therapeutic agents available. Although many tools and regimens are available, no one by itself is enough for an adequate management of the patient. But rather, combined therapy and individualization of approaches are recommended for better results. We suggest that new studies analyzing the effectiveness of therapeutic approaches to the management of secondary hyperparathyroidism should be directed not only to controlling parathyroid hormone levels but also to the evaluation of long-term outcomes, based on modification of morbidity, mortality, and end organ impact, while reducing side effects and controlling costs, among others.
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Affiliation(s)
- Ezequiel Bellorin-Font
- Division of Nephrology and Hypertension, Saint Louis University, Saint Louis, MO, 63110, USA
| | - George Vasquez-Rios
- Division of Nephrology and Hypertension, Saint Louis University, Saint Louis, MO, 63110, USA
| | - Kevin J Martin
- Division of Nephrology and Hypertension, Saint Louis University, Saint Louis, MO, 63110, USA.
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Abstract
RATIONALE It is rare to find 22q11.2 deletion syndrome with pseudohypoparathyroidism in children. Furthermore, the phenotypic spectrum of this disorder varies widely. PATIENT CONCERNS A patient was diagnosed with pseudohypoparathyroidism at age 14 years because of convulsions, hypocalcemia, hyperphosphatemia, normal parathyroid hormone levels, and basal ganglia calcifications. Thereafter, the child presented with symptoms of nephrotic syndrome; subsequently, he was diagnosed with nephrotic syndrome at the local hospital. DIAGNOSIS At our hospital, multiplex ligation-dependent probe amplification confirmed that the patient had 22q11.2 deletion syndrome. INTERVENTIONS The patient continued to be treated with calcium supplements. OUTCOMES Seizure activity and proteinuria ceased. LESSONS Signs of this syndrome include delayed speech development due to velofacial dysfunction, recurrent croup attacks during early childhood due to latent hypocalcemia, and mild dysmorphic features. The findings of this patient indicated that 22q11.2 deletion syndrome may include a wide spectrum of clinical findings and that this diagnosis needs to be considered for all patients presenting with hypocalcemia, regardless of age.
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Affiliation(s)
| | | | - Jing-Yu Jia
- Department of Orthopaedics, The Second Affiliated Hospital of Nanchang University, Nanchang City, China
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Affiliation(s)
- Rachel I Gafni
- From the Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD
| | - Michael T Collins
- From the Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD
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49
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Kapoian T, Khalil S, O'Mara NB, Brink DM, Daugirdas JT. Modeled Daily Ingested, Absorbed and Bound Phosphorus: New Measures of Mineral Balance in Hemodialysis Patients. Am J Nephrol 2019; 49:368-376. [PMID: 30939469 DOI: 10.1159/000499438] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 03/01/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Control of predialysis serum phosphorus in hemodialysis patients is challenging. We explored the utility of a novel kinetic phosphorus modeling program. METHODS As part of a quality assurance program, urea kinetic modeling results were combined with those from phosphorus kinetic modeling to compute modeled daily ingested phosphorus (DIP) and components making up this metric, including absorbed, bound, and nonabsorbed, nonbound phosphorus. RESULTS In 182 hemodialysis patients, DIP averaged 1,089 ± 348 mg/day in men and 934 ± 292 in women (p < 0.002) and correlated substantially with body weight. DIP/kg bodyweight (12.8 ± 3.40 mg/kg) was not significantly different between the sexes. Prescribed equivalent binder dose (EBD) was 4.98 ± 3.61 and 4.53 ± 3.02 g/day in men and women, respectively (p NS). Protein catabolic rate (PCR) was significantly higher in men (64.4 ± 18) g/day vs. women (48.2 ± 15.6, p < 0.001), and the DIP/PCR ratio was 17.4 ± 4.81 in men vs. 20.1 ± 5.76 in women (p < 0.001). Presence of residual kidney function was associated with a lower prescribed EBD dose (4.08 ± 2.62 vs. 5.38 ± 3.81 g/day, p < 0.01). Self-reported poor binder compliance was associated with higher DIP or DIP/kg as well as higher prescribed EBD. In anuric patients, DIP/kg was increased in patients consuming diets with high phosphate additive content and those reporting poor compliance with the prescribed dose of phosphate binders. CONCLUSIONS The combination of urea kinetic and phosphorus modeling can be used to estimate measures related to phosphorus intake. High DIP/PCR or DIP/kg body weight values in anuric patients suggest consumption of a diet high in phosphorus additives or noncompliance with the prescribed amount of phosphorus binders.
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Affiliation(s)
- Toros Kapoian
- Rutgers, Robert Wood Johnson Medical School, Dialysis Clinic, Inc., North Brunswick, New Jersey, USA
| | - Steven Khalil
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | | | - Diane M Brink
- Dialysis Clinic, Inc., North Brunswick, New Jersey, USA
| | - John T Daugirdas
- Department of Medicine, University of Illinois College of Medicine, Chicago, Illinois, USA,
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50
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Lioufas N, Toussaint ND, Pedagogos E, Elder G, Badve SV, Pascoe E, Valks A, Hawley C. Can we IMPROVE cardiovascular outcomes through phosphate lowering in CKD? Rationale and protocol for the IMpact of Phosphate Reduction On Vascular End-points in Chronic Kidney Disease (IMPROVE-CKD) study. BMJ Open 2019; 9:e024382. [PMID: 30796122 PMCID: PMC6398689 DOI: 10.1136/bmjopen-2018-024382] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Patients with chronic kidney disease (CKD) are at heightened cardiovascular risk, which has been associated with abnormalities of bone and mineral metabolism. A deeper understanding of these abnormalities should facilitate improved treatment strategies and patient-level outcomes, but at present there are few large, randomised controlled clinical trials to guide management. Positive associations between serum phosphate and fibroblast growth factor 23 (FGF-23) and cardiovascular morbidity and mortality in both the general and CKD populations have resulted in clinical guidelines suggesting that serum phosphate be targeted towards the normal range, although few randomised and placebo-controlled studies have addressed clinical outcomes using interventions to improve phosphate control. Early preventive measures to reduce the development and progression of vascular calcification, left ventricular hypertrophy and arterial stiffness are crucial in patients with CKD. METHODS AND ANALYSIS We outline the rationale and protocol for an international, multicentre, randomised parallel-group trial assessing the impact of the non-calcium-based phosphate binder, lanthanum carbonate, compared with placebo on surrogate markers of cardiovascular disease in a predialysis CKD population-the IM pact of P hosphate R eduction O n V ascular E nd-points (IMPROVE)-CKD study. The primary objective of the IMPROVE-CKD study is to determine if the use of lanthanum carbonate reduces the burden of cardiovascular disease in patients with CKD stages 3b and 4 when compared with placebo. The primary end-point of the study is change in arterial compliance measured by pulse wave velocity over a 96-week period. Secondary outcomes include change in aortic calcification and biochemical parameters of serum phosphate, parathyroid hormone and FGF-23 levels. ETHICS AND DISSEMINATION Ethical approval for the IMPROVE-CKD trial was obtained by each local Institutional Ethics Committee for all 17 participating sites in Australia, New Zealand and Malaysia prior to study commencement. Results of this clinical trial will be published in peer-reviewed journals and presented at conferences. TRIAL REGISTRATION NUMBER ACTRN12610000650099.
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Affiliation(s)
- Nicole Lioufas
- Department of Nephrology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Nigel D Toussaint
- Department of Nephrology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | | | - Grahame Elder
- Department of Renal Medicine, Westmead Hospital, Sydney, New South Wales, Australia
| | - Sunil V Badve
- Department of Nephrology, St. George Hospital, Sydney, New South Wales, Australia
| | - Elaine Pascoe
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Australasian Kidney Trials Network, Brisbane, Queensland, Australia
| | - Andrea Valks
- University of Queensland, Australasian Kidney Trials Network, Brisbane, Queensland, Australia
| | - Carmel Hawley
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Australasian Kidney Trials Network, Brisbane, Queensland, Australia
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