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Molina P, Molina MD, Carrero JJ, Escudero V, Torralba J, Castro-Alonso C, Beltrán S, Vizcaíno B, González-Moya M, Kanter J, Sancho-Calabuig A, Bover J, Górriz JL. Sevelamer Use and Mortality in People with Chronic Kidney Disease Stages 4 and 5 Not on Dialysis. J Clin Med 2023; 12:7631. [PMID: 38137700 PMCID: PMC10743559 DOI: 10.3390/jcm12247631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 11/27/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023] Open
Abstract
Rationale and objective: Data suggest that non-calcium-based binders, and specifically sevelamer, may lead to lower rates of death when compared with calcium-based binders in end-stage renal disease (ESRD) patients. However, the association between sevelamer use and mortality for those with non-dialysis-dependent chronic kidney disease (NDD-CKD) patients has been uncertain. Study design: Our research is presented in a prospective cohort study. Setting and participants: A total of 966 participants with NDD-CKD stages 4-5 were enrolled in the PECERA study from 12 centers in Spain. Exposure: The participants were treated with sevelamer. Outcome: This study yielded all-cause and cardiovascular mortality outcomes. Analytical approach: We conducted an association analysis between mortality and sevelamer use with time-dependent Cox proportional hazards models. Results: After a median follow-up of 29 months (IQR: 13-36 months), death occurred in 181 participants (19%), with cardiovascular (n = 95, 53%) being the leading cause of death. In a multivariable model, the adjusted hazard ratios (HRs) for patients under sevelamer treatment were 0.44 (95% CI, 0.22 to 0.88) and 0.37 (95% CI, 0.18 to 0.75) for all-cause and cardiovascular mortality, respectively, compared with those of untreated patients. Limitations: Some limitations include potential confusion via indication bias; causal statements about these associations cannot be made due to the observational nature of this study. Conclusions: In this prospective NDD-CKD cohort study, the administration of sevelamer was independently associated with lower all-cause and cardiovascular mortality, suggesting that non-calcium-based phosphate binders might be the first-line therapy for phosphate lowering in this population. Further interventional studies clarifying the risks and benefits of phosphate binders in NDD-CKD are warranted.
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Affiliation(s)
- Pablo Molina
- Department of Nephrology, Hospital Universitari Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana, 46017 Valencia, Spain; (V.E.); (C.C.-A.); (S.B.); (B.V.); (M.G.-M.); (J.K.); (A.S.-C.)
- Department of Medicine, Universitat de València, 46010 Valencia, Spain;
| | - Mariola D. Molina
- Department of Mathematics, Universidad de Alicante, 03690 Sant Vicent del Raspeig, Spain;
| | - Juan J. Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, SE-171 77 Stockholm, Sweden;
| | - Verónica Escudero
- Department of Nephrology, Hospital Universitari Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana, 46017 Valencia, Spain; (V.E.); (C.C.-A.); (S.B.); (B.V.); (M.G.-M.); (J.K.); (A.S.-C.)
| | - Javier Torralba
- Department of Nephrology, Hospital General Universitario, 03010 Alicante, Spain;
| | - Cristina Castro-Alonso
- Department of Nephrology, Hospital Universitari Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana, 46017 Valencia, Spain; (V.E.); (C.C.-A.); (S.B.); (B.V.); (M.G.-M.); (J.K.); (A.S.-C.)
| | - Sandra Beltrán
- Department of Nephrology, Hospital Universitari Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana, 46017 Valencia, Spain; (V.E.); (C.C.-A.); (S.B.); (B.V.); (M.G.-M.); (J.K.); (A.S.-C.)
| | - Belén Vizcaíno
- Department of Nephrology, Hospital Universitari Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana, 46017 Valencia, Spain; (V.E.); (C.C.-A.); (S.B.); (B.V.); (M.G.-M.); (J.K.); (A.S.-C.)
- Department of Medicine, Universitat de València, 46010 Valencia, Spain;
| | - Mercedes González-Moya
- Department of Nephrology, Hospital Universitari Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana, 46017 Valencia, Spain; (V.E.); (C.C.-A.); (S.B.); (B.V.); (M.G.-M.); (J.K.); (A.S.-C.)
- Department of Medicine, Universitat de València, 46010 Valencia, Spain;
| | - Julia Kanter
- Department of Nephrology, Hospital Universitari Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana, 46017 Valencia, Spain; (V.E.); (C.C.-A.); (S.B.); (B.V.); (M.G.-M.); (J.K.); (A.S.-C.)
| | - Asunción Sancho-Calabuig
- Department of Nephrology, Hospital Universitari Dr. Peset, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana, 46017 Valencia, Spain; (V.E.); (C.C.-A.); (S.B.); (B.V.); (M.G.-M.); (J.K.); (A.S.-C.)
- Department of Medicine, Universitat de València, 46010 Valencia, Spain;
| | - Jordi Bover
- Nephrology Department, University Hospital Germans Trias i Pujol, 08916 Badalona, Spain;
| | - José L. Górriz
- Department of Medicine, Universitat de València, 46010 Valencia, Spain;
- Department of Nephrology, Hospital Clínico Universitario, Fundación para la Investigación del Hospital Clínico de la Comunidad Valenciana, 46010 Valencia, Spain
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Mok Y, Wang F, Ballew SH, Menez S, Butler KR, Wagenknecht L, Sedaghat S, Lutsey PL, Coresh J, Blaha MJ, Matsushita K. Kidney function, bone-mineral metabolism markers, and calcification of coronary arteries, aorta, and cardiac valves in older adults. Atherosclerosis 2023; 368:35-43. [PMID: 36754659 PMCID: PMC9992265 DOI: 10.1016/j.atherosclerosis.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/10/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND AIMS The contribution of kidney dysfunction, especially at mild-to-moderate stages, and bone-mineral metabolism (BMM) markers to vascular calcification remains controversial or unclear. We comprehensively evaluated the association of kidney and BMM markers with coronary artery calcification (CAC) and extra-coronary calcification (ECC). METHODS In 1931 ARIC participants (age 73-95 years) without coronary heart disease at visit 7 (2018-19), we investigated the associations of estimated glomerular filtration rate (eGFR) (with creatinine, cystatin C, and both) and five serum BMM markers (calcium, fibroblast growth factor 23, magnesium, parathyroid hormone, and phosphorus) with high CAC and ECC (sex-race specific ≥75th vs. <75th percentile Agatston score) or any vs. zero CAC and ECC using multivariable logistic regression. For eGFR and BMM markers, we took their weighted cumulative averages from visit 1 (1987-89) to visit 5 (2011-13). RESULTS Lower eGFR, regardless of equations used, was not robustly associated with high CAC or ECC. Among BMM markers, only higher phosphorus levels, even within the normal range, showed robust associations with high CAC (only when modeled continuously) and ECC, independently of kidney function (e.g., odds ratio 1.94 [95%CI 1.38-2.73] for high aortic valve calcification, in the highest vs. lowest quartile). Results were generally consistent when analyzing any CAC or ECC, although cystatin C-based eGFR <60 mL/min/1.73 m2 became significantly associated with mitral valve calcification (odds ratio 1.69 [1.10-2.60]). CONCLUSIONS Among kidney and BMM measures tested, only serum phosphorus demonstrated robust associations with both CAC and ECC, supporting a key role of phosphorus in the pathophysiology of vascular calcification.
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Affiliation(s)
- Yejin Mok
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Frances Wang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Shoshana H Ballew
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Steve Menez
- Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Kenneth R Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Lynne Wagenknecht
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Sanaz Sedaghat
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Pamela L Lutsey
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Michael J Blaha
- Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD, USA.
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A Comparison Between the Effects of Calcium Acetate and Sevelamer Carbonate on Progression of Aortic Vascular Calcification in Patients with Chronic Kidney Disease Stages 4 and 5. Nephrourol Mon 2022. [DOI: 10.5812/numonthly-120721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Calcium-based and non-calcium-based phosphate binders are frequently used to treat hyperphosphatemia in patients with chronic kidney disease (CKD). Objectives: This study aimed to compare the effects of calcium acetate and sevelamer carbonate on the progression of aortic vascular calcification in patients with CKD stages 4 and 5. Methods: This was an open-label randomized prospective comparative study, in which the participants encompassed both male and female patients with ambulatory hyperphosphatemic CKD stages 4 and 5 aged above 18 years. One hundred fifty patients with CKD stages 4 and 5 were screened for Aortic vascular calcification using digital X-ray lumbar spine and multi-slice CT scan, of whom fifty patients with vascular calcification were selected and randomly assigned into two groups. The participants were then serially studied for the effects of phosphate binders on the progression of vascular calcification over one year. One group was prescribed calcium acetate, and the other group was prescribed sevelamer carbonate. Results: Fifty hyperphosphatemic CKD patients with a mean age of 57 years were randomly assigned into two groups. There was no statistically significant difference between the two groups; however, the patients assigned to the sevelamer group were older and higher aortic calcification index (ACI) (P = 0.035) and Kauppila scores (P = 0.04), and elevated serum calcium (P = 0.04), Ca X PO4 (P = 0.006), and vitamin D. In calcium acetate-treated patients, the mean ACI increased significantly during six months and one year; however, the increase was not significant in the sevelamer group. Serum cholesterol, serum triglycerides, serum iPTH level, and the inflammatory markers of atherosclerosis high sensitivity of C-reactive protein (hs-CRP), interleukin-6 (IL-6) (hs-CRP, IL-6) decreased significantly in the sevelamer group. Conclusions: The prevalence of vascular (abdominal aortic) calcification in pre-ESRD (CKD stage 4 and 5) patients was 75%. Abdominal aortic calcification increased significantly in calcium acetate-treated patients during six months and one year; however, the progression was not significant regarding sevelamer. Because of its pleiotropic properties, sevelamer is more effective and consistent in retarding the progression of vascular calcification than calcium acetate in patients with CKD stages 4 and 5.
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Teong LF, Khor BH, Radion Purba K, Gafor AHA, Goh BL, Bee BC, Yahya R, Bavanandan S, Ng HM, Sahathevan S, Narayanan SS, Daud ZAM, Khosla P, Karupaiah T. A Mobile App for Triangulating Strategies in Phosphate Education Targeting Patients with Chronic Kidney Disease in Malaysia: Development, Validation, and Patient Acceptance. Healthcare (Basel) 2022; 10:healthcare10030535. [PMID: 35327013 PMCID: PMC8950478 DOI: 10.3390/healthcare10030535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 02/25/2022] [Accepted: 03/10/2022] [Indexed: 11/16/2022] Open
Abstract
Hyperphosphatemia afflicts end-stage chronic kidney disease (CKD) patients, contributing to comorbidities and mortality. Management strategies are dialysis, phosphate binder, and limiting dietary phosphate intake, but treatment barriers are poor patient compliance and low health literacy arising from low self-efficacy and lack of educational resources. This study describes developing and validating a phosphate mobile application (PMA). The PMA development based on the seven-stage Precaution Adoption Process Model prioritized titrating dietary phosphate intake with phosphate binder dose supported by educational videography. Experts (n = 13) first evaluated the PMA for knowledge-based accuracy, mobile heuristics, and clinical value. Adult HD patients validated the improved PMA using the seven-point mHealth App Usability Questionnaire (MAUQ). Patient feedback (n = 139) indicated agreement for ease of use (69.2%), interface and satisfaction (69.0%), and usefulness (70.1%), while 72.7% said they would recommend this PMA. The expectation confirmation for 25 PMA features ranged from 92.1% (lifestyle) up to 100.0% (language option); and the utilization rate of each feature varied from 21.6% (goal setting and feature-based log) to 91.4% (information on dietary phosphate and phosphate binder). The Conclusions: MyKidneyDiet-Phosphate Tracker PMA was acceptable to adult Malaysian HD patients as part of clinical phosphate management in low-resource settings.
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Affiliation(s)
- Lee-Fang Teong
- School of Biosciences, Faculty of Health and Medical Sciences, Taylor’s University, Subang Jaya 47500, Malaysia; (L.-F.T.); (S.S.N.)
- Department of Dietetics and Food Service, Selayang Hospital, Batu Caves 68100, Malaysia
| | - Ban-Hock Khor
- Faculty of Food Science and Nutrition, Universiti Malaysia Sabah, Kota Kinabalu 88400, Malaysia;
| | - Kristo Radion Purba
- School of Computer Science, University of Southampton Malaysia, Iskandar Puteri 79100, Malaysia;
| | - Abdul Halim Abdul Gafor
- Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur 56000, Malaysia;
| | - Bak-Leong Goh
- Clinical Research Center, Serdang Hospital, Kajang 43000, Malaysia;
| | - Boon-Cheak Bee
- Department of Nephrology, Selayang Hospital, Lebuh Raya Selayang-Kepong, Batu Caves 68100, Malaysia;
| | - Rosnawati Yahya
- Department of Nephrology, Kuala Lumpur Hospital, Jalan Pahang, Kuala Lumpur 53000, Malaysia; (R.Y.); (S.B.)
| | - Sunita Bavanandan
- Department of Nephrology, Kuala Lumpur Hospital, Jalan Pahang, Kuala Lumpur 53000, Malaysia; (R.Y.); (S.B.)
| | - Hi-Ming Ng
- School of Medicine, Faculty of Health and Medical Sciences, Taylor’s University, Subang Jaya 47500, Malaysia;
- Department of Dietetics & Nutrition Services, Sunway Medical Center, Petaling Jaya 47500, Malaysia
| | - Sharmela Sahathevan
- Department of Allied Health Sciences, Faculty of Science, Universiti Tunku Abdul Rahman, Kampar 31900, Malaysia;
| | - Sreelakshmi Sankara Narayanan
- School of Biosciences, Faculty of Health and Medical Sciences, Taylor’s University, Subang Jaya 47500, Malaysia; (L.-F.T.); (S.S.N.)
| | - Zulfitri Azuan Mat Daud
- Department of Nutrition and Dietetics, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang 43400, Malaysia;
| | - Pramod Khosla
- Department of Nutrition & Food Sciences, College of Liberal Arts & Sciences, Wayne State University, Detroit, MI 48202, USA;
| | - Tilakavati Karupaiah
- School of Biosciences, Faculty of Health and Medical Sciences, Taylor’s University, Subang Jaya 47500, Malaysia; (L.-F.T.); (S.S.N.)
- Correspondence:
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Food-Related Carbonyl Stress in Cardiometabolic and Cancer Risk Linked to Unhealthy Modern Diet. Nutrients 2022; 14:nu14051061. [PMID: 35268036 PMCID: PMC8912422 DOI: 10.3390/nu14051061] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 02/01/2023] Open
Abstract
Carbonyl stress is a condition characterized by an increase in the steady-state levels of reactive carbonyl species (RCS) that leads to accumulation of their irreversible covalent adducts with biological molecules. RCS are generated by the oxidative cleavage and cellular metabolism of lipids and sugars. In addition to causing damage directly, the RCS adducts, advanced glycation end-products (AGEs) and advanced lipoxidation end-products (ALEs), cause additional harm by eliciting chronic inflammation through receptor-mediated mechanisms. Hyperglycemia- and dyslipidemia-induced carbonyl stress plays a role in diabetic cardiovascular complications and diabetes-related cancer risk. Moreover, the increased dietary exposure to AGEs/ALEs could mediate the impact of the modern, highly processed diet on cardiometabolic and cancer risk. Finally, the transient carbonyl stress resulting from supraphysiological postprandial spikes in blood glucose and lipid levels may play a role in acute proinflammatory and proatherogenic changes occurring after a calorie dense meal. These findings underline the potential importance of carbonyl stress as a mediator of the cardiometabolic and cancer risk linked to today’s unhealthy diet. In this review, current knowledge in this field is discussed along with future research courses to offer new insights and open new avenues for therapeutic interventions to prevent diet-associated cardiometabolic disorders and cancer.
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Xu C, Smith ER, Tiong MK, Ruderman I, Toussaint ND. Interventions to Attenuate Vascular Calcification Progression in Chronic Kidney Disease: A Systematic Review of Clinical Trials. J Am Soc Nephrol 2022; 33:1011-1032. [PMID: 35232774 PMCID: PMC9063901 DOI: 10.1681/asn.2021101327] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 02/16/2022] [Indexed: 11/03/2022] Open
Abstract
Background Vascular calcification is associated with cardiovascular morbidity and mortality in people with chronic kidney disease (CKD). Evidence-based interventions that may attenuate its progression in CKD remain uncertain.
Methods We conducted a systematic review of prospective clinical trials of interventions to attenuate vascular calcification in people with CKD, compare with placebo, another comparator, or standard of care. We included prospective clinical trials (randomized and nonrandomized) involving participants with stage 3-5D CKD or kidney transplant recipients; the outcome was vascular calcification measured using radiological methods. Quality of evidence was determined by the Cochrane risk of bias assessment tool and the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) method.
Results There were 77 trials (63 randomized) involving 6898 participants eligible for inclusion (median sample size, 50; median duration, 12 months); 58 involved participants on dialysis, 15 involved individuals with nondialysis CKD, and 4 involved kidney transplant recipients. Risk of bias was moderate over all. Trials involving magnesium and sodium thiosulfate consistently showed attenuation of vascular calcification. Trials involving intestinal phosphate binders, alterations in dialysate calcium concentration, vitamin K therapy, calcimimetics, and antiresorptive agents had conflicting or inconclusive outcomes. Trials involving vitamin D therapy and HMG-CoA reductase inhibitors did not demonstrate attenuation of vascular calcification. Mixed results were reported for single studies of exercise, vitamin E-coated or high-flux hemodialysis membranes, interdialytic sodium bicarbonate, SNF472, spironolactone, sotatercept, nicotinamide, and oral activated charcoal.
Conclusions Currently, there are insufficient or conflicting data regarding interventions evaluated in clinical trials for mitigation of vascular calcification in people with CKD. Therapy involving magnesium or sodium thiosulfate appears most promising, but evaluable studies were small and of short duration.
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Affiliation(s)
- Chelsea Xu
- Department of Medicine, University of Melbourne, Parkville, Australia
| | - Edward R Smith
- Department of Medicine, University of Melbourne, Parkville, Australia
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
| | - Mark K Tiong
- Department of Medicine, University of Melbourne, Parkville, Australia
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
| | - Irene Ruderman
- Department of Medicine, University of Melbourne, Parkville, Australia
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
| | - Nigel D Toussaint
- Department of Medicine, University of Melbourne, Parkville, Australia
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
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Leifheit-Nestler M, Vogt I, Haffner D, Richter B. Phosphate Is a Cardiovascular Toxin. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1362:107-134. [DOI: 10.1007/978-3-030-91623-7_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Lioufas NM, Pascoe EM, Hawley CM, Elder GJ, Badve SV, Block GA, Johnson DW, Toussaint ND. Systematic Review and Meta-Analyses of the Effects of Phosphate-Lowering Agents in Nondialysis CKD. J Am Soc Nephrol 2022; 33:59-76. [PMID: 34645696 PMCID: PMC8763193 DOI: 10.1681/asn.2021040554] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 09/22/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Benefits of phosphate-lowering interventions on clinical outcomes in patients with CKD are unclear; systematic reviews have predominantly involved patients on dialysis. This study aimed to summarize evidence from randomized controlled trials (RCTs) concerning benefits and risks of noncalcium-based phosphate-lowering treatment in nondialysis CKD. METHODS We conducted a systematic review and meta-analyses of RCTs involving noncalcium-based phosphate-lowering therapy compared with placebo, calcium-based binders, or no study medication, in adults with CKD not on dialysis or post-transplant. RCTs had ≥3 months follow-up and outcomes included biomarkers of mineral metabolism, cardiovascular parameters, and adverse events. Outcomes were meta-analyzed using the Sidik-Jonkman method for random effects. Unstandardized mean differences were used as effect sizes for continuous outcomes with common measurement units and Hedge's g standardized mean differences (SMD) otherwise. Odds ratios were used for binary outcomes. Cochrane risk of bias and GRADE assessment determined the certainty of evidence. RESULTS In total, 20 trials involving 2498 participants (median sample size 120, median follow-up 9 months) were eligible for inclusion. Overall, risk of bias was low. Compared with placebo, noncalcium-based phosphate binders reduced serum phosphate (12 trials, weighted mean difference -0.37; 95% CI, -0.58 to -0.15 mg/dl, low certainty evidence) and urinary phosphate excretion (eight trials, SMD -0.61; 95% CI, -0.90 to -0.31, low certainty evidence), but resulted in increased constipation (nine trials, log odds ratio [OR] 0.93; 95% CI, 0.02 to 1.83, low certainty evidence) and greater vascular calcification score (three trials, SMD, 0.47; 95% CI, 0.17 to 0.77, very low certainty evidence). Data for effects of phosphate-lowering therapy on cardiovascular events (log OR, 0.51; 95% CI, -0.51 to 1.17) and death were scant. CONCLUSIONS Noncalcium-based phosphate-lowering therapy reduced serum phosphate and urinary phosphate excretion, but there was an unclear effect on clinical outcomes and intermediate cardiovascular end points. Adequately powered RCTs are required to evaluate benefits and risks of phosphate-lowering therapy on patient-centered outcomes.
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Affiliation(s)
- Nicole M. Lioufas
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia,Department of Medicine, University of Melbourne, Parkville, Australia,Department of Nephrology, Western Health, Melbourne, Australia
| | | | - Carmel M. Hawley
- Australasian Kidney Trials Network, Brisbane, Australia,Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia,Translational Research Institute, Brisbane, Australia
| | - Grahame J. Elder
- School of Medicine, University of Notre Dame, Sydney, Australia,Department of Medicine, University of Sydney, Sydney, Australia,Osteoporosis and Bone Biology Division, Garvan Institute of Medical Research, Darlinghurst, Australia,Department of Nephrology, Westmead Hospital, Sydney, Australia
| | - Sunil V. Badve
- Australasian Kidney Trials Network, Brisbane, Australia,Department of Nephrology, St. George Hospital, Sydney, Australia,Renal and Metabolic Division, the George Institute for Global Health, University of New South Wales, Sydney, Australia
| | | | - David W. Johnson
- Australasian Kidney Trials Network, Brisbane, Australia,Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia,Translational Research Institute, Brisbane, Australia
| | - Nigel D. Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia,Department of Medicine, University of Melbourne, Parkville, Australia
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9
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Hernandes FR, Goldenstein P, Custódio MR. Treatment of Hyperparathyroidism (SHPT). J Bras Nefrol 2021; 43:645-649. [PMID: 34910799 PMCID: PMC8823921 DOI: 10.1590/2175-8239-jbn-2021-s107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 07/01/2021] [Indexed: 11/21/2022] Open
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10
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Basutkar RS, Varghese R, Mathew NK, Sankar Indira P, Viswanathan B, Sivasankaran P. Systematic review and meta-analysis of potential pleiotropic effects of sevelamer in chronic kidney disease: Beyond phosphate control. Nephrology (Carlton) 2021; 27:337-354. [PMID: 34882904 DOI: 10.1111/nep.14011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 12/01/2021] [Accepted: 12/05/2021] [Indexed: 11/26/2022]
Abstract
Sevelamer, has been shown to have many pleiotropic actions on lipid panel, various inflammatory markers, and blood glucose levels in chronic kidney disease patients. We conducted a systematic review and meta-analysis to compare these pleiotropic effects of sevelamer to other phosphate binders used in chronic kidney disease patients. The relevant randomized controlled trials published from 1 January 2001 to 31 November 2019 on the following databases: Cochrane Central Register of Controlled Trials published in The Cochrane Library, PubMed, Scopus and Google Scholar were identified. All the included studies were independently assessed for eligibility and risk of bias. The modified data extraction form of Cochrane was used. This review included 44 studies for qualitative analysis and 28 reports for quantitative analysis. A meta-analysis of three studies (n = 180) showed that glycated haemoglobin had significantly decreased in sevelamer-treated patients (MD: 0.5%; p = <.001). Compared with calcium-based phosphate binders, sevelamer showed a significant reduction in low-density lipoprotein (MD: -19.43 mg/dL; p = <.001) and total cholesterol (MD: -19.98 mg/dL; p < .001). A significant increase in high-density lipoprotein (MD: 1.29 mg/dL; p = .05) was also prominent in sevelamer treated patients. However, we were not able to observe a significant change in other biochemical parameters such as TG, CRP, hs-CRP, FGF-23, IL-6 and albumin as, no statistically significant difference was observed.
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Affiliation(s)
- Roopa Satyanarayan Basutkar
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, Tamil Nadu, India
| | - Resia Varghese
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, Tamil Nadu, India
| | - Nina Kallanthanath Mathew
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, Tamil Nadu, India
| | - Prithika Sankar Indira
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, Tamil Nadu, India
| | | | - Ponnusankar Sivasankaran
- Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Ooty, Tamil Nadu, India
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Makowka A, Nowicki M. Different Effect of Lanthanum Carbonate and Sevelamer Hydrochloride on Calcium Balance in Patients with Moderate to Advanced Chronic Kidney Disease. Ther Clin Risk Manag 2021; 17:1145-1151. [PMID: 34754193 PMCID: PMC8572109 DOI: 10.2147/tcrm.s330649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 09/28/2021] [Indexed: 11/23/2022] Open
Abstract
Objective Opposite to lanthanum carbonate (LC), sevelamer hydrochloride (SH) may increase intestinal calcium absorption. The study compared the effects of LC and SH on serum and urine phosphate and calcium, and on hormones regulating mineral-bone metabolism. Patients and Methods A prospective randomized crossover study included 34 patients with eGFR <60 mL/min. A single oral dose of LC (1,000 mg) or SH (2,400 mg) was administered in random order 15 minutes after a standardized meal fortified with 5 g calcium carbonate. Serum calcium, phosphate, and parathormone were measured before and 3, 6, 12, and 24 hours after each medication. Bone alkaline phosphatase (BAP), sclerostin, calcitriol, and FGF-23 were measured at baseline and after 12 and 24 hours. A 24-hour calcium and phosphate excretion was measured after each drug. Results Serum calcium increased 3 and 6 hours after SH then returned to baseline. After LC calcium was unchanged for up to 3 hours then transiently increased and eventually returned to baseline. The area under curve (AUC) of serum calcium for 12 hours after SH was larger than after LC (p=0.04). Serum phosphate decreased after each drug with a nadir 3 hours post-SH and 6 hours post-LC. AUC of serum phosphate was similar after both medications. PTH decreased transiently after both drugs. BAP did not change. FGF-23 was constant for the first 12 hours but later decreased after each drug. Conclusion A 2,400 mg SH and 1,000 mg LC are similarly effective in lowering serum phosphate in CKD, but LC induce in less intestinal calcium absorption after a meal. The trial was registered on February 23, 2018 in the clinicaltrial.gov database – NCT03451019.
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Affiliation(s)
- Agnieszka Makowka
- Department of Nephrology, Hypertension and Kidney Transplantation, Medical University of Lodz, Lodz, Poland
| | - Michal Nowicki
- Department of Nephrology, Hypertension and Kidney Transplantation, Medical University of Lodz, Lodz, Poland
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12
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Chen W, Han Q, Liu Y, Wang Y, Liu F. Targeted perfusion adsorption for hyperphosphatemia using mixed matrix microspheres (MMMs) encapsulated NH 2-MIL-101(Fe). J Mater Chem B 2021; 9:4555-4566. [PMID: 34047320 DOI: 10.1039/d1tb00329a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Hyperphosphatemia, a common complication of chronic renal failure patients, is described as an excess amount of serum phosphate >4.5 mg dL-1. Current therapy for hyperphosphatemia is limited by low removal efficiency, secondary hyperparathyroidism, uremic bone disease, and the promotion of vascular and visceral calcifications. Metal organic frameworks (MOFs) have aroused great interest in the field of blood purification because of their strong specific adsorption. Herein, we prepared mixed matrix microspheres (MMMs) encapsulated NH2-MIL-101(Fe) with specific adsorption to blood phosphate. Simultaneously, a heparinoid copolymer poly (acrylic acid-sodium 4-vinylbenzenssulfonate) (P(AA-SSNa)) was incorporated to improve the hemocompatibility. The proposed MMMs exhibited excellent phosphate adsorption capacity both in aqueous and human plasma environments. They also showed comprehensive hemocompatibility e.g. low tendency of protein adsorption, low hemolysis rate and extended blood coagulation time. In general, we envision that the MMMs are potentially suitable as highly efficient hemoperfusion adsorbents for hyperphosphatemia treatment.
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Affiliation(s)
- Wenhui Chen
- Key Laboratory of Marine Materials and Related Technologies, Zhejiang Key Laboratory of Marine Materials and Protective Technologies, Ningbo Institute of Materials Technology & Engineering, Chinese Academy of Sciences, No. 1219 Zhongguan West Rd, Ningbo 315201, China. and Nano Science and Technology Institute, University of Science and Technology of China, Suzhou 215000, China
| | - Qiu Han
- Key Laboratory of Marine Materials and Related Technologies, Zhejiang Key Laboratory of Marine Materials and Protective Technologies, Ningbo Institute of Materials Technology & Engineering, Chinese Academy of Sciences, No. 1219 Zhongguan West Rd, Ningbo 315201, China.
| | - Yang Liu
- Key Laboratory of Marine Materials and Related Technologies, Zhejiang Key Laboratory of Marine Materials and Protective Technologies, Ningbo Institute of Materials Technology & Engineering, Chinese Academy of Sciences, No. 1219 Zhongguan West Rd, Ningbo 315201, China. and University of Chinese Academy of Sciences, 19 A Yuquan Rd, Shijingshan District, Beijing 100049, China
| | - Yiwen Wang
- Key Laboratory of Marine Materials and Related Technologies, Zhejiang Key Laboratory of Marine Materials and Protective Technologies, Ningbo Institute of Materials Technology & Engineering, Chinese Academy of Sciences, No. 1219 Zhongguan West Rd, Ningbo 315201, China. and University of Chinese Academy of Sciences, 19 A Yuquan Rd, Shijingshan District, Beijing 100049, China
| | - Fu Liu
- Key Laboratory of Marine Materials and Related Technologies, Zhejiang Key Laboratory of Marine Materials and Protective Technologies, Ningbo Institute of Materials Technology & Engineering, Chinese Academy of Sciences, No. 1219 Zhongguan West Rd, Ningbo 315201, China. and University of Chinese Academy of Sciences, 19 A Yuquan Rd, Shijingshan District, Beijing 100049, China
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13
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Phannajit J, Wonghakaeo N, Takkavatakarn K, Asawavichienjinda T, Praditpornsilpa K, Eiam-Ong S, Susantitaphong P. The impact of phosphate lowering agents on clinical and laboratory outcomes in chronic kidney disease patients: a systematic review and meta-analysis of randomized controlled trials. J Nephrol 2021; 35:473-491. [PMID: 34061337 DOI: 10.1007/s40620-021-01065-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 05/09/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Besides reducing hyperphosphatemia in chronic kidney disease (CKD) patients, phosphate lowering agents might provide beneficial effects on clinical and laboratory parameters. This meta-analysis was conducted to comprehensively examine the impact of all phosphate lowering agents on various aspects of clinical and laboratory outcomes in CKD patients. METHOD A systematic literature search was performed in MEDLINE, Scopus, and the Cochrane Register of Controlled Trials until July 2020 to identify randomized controlled trials (RCTs) which compared the effects of each phosphate lowering agent with controls, comprising placebo and all other phosphate lowering agents. Various clinical and laboratory outcomes were analyzed. Random effects model was used to compute the standardized mean difference for continuous variables and the risk ratio (RR) for binary variables. RESULTS This meta-analysis included 127 RCTs with 20,215 patients. Sevelamer and lanthanum significantly reduced all-cause mortality (RR 0.610, 95% CI 0.401-0.929 and 0.467, 95% CI 0.337-0.647, respectively) but not cardiovascular (CV) mortality or CV events. Hospitalization rates were significantly diminished by sevelamer (RR 0.527; 95% CI 0.308-0.902). Certain phosphate lowering agents improved biochemical parameters including serum phosphate, calcium, coronary artery calcium scores, fibroblast growth factor-23, bone biomarkers, and lipid profiles. Intact parathyroid hormone and bone mineral density were not significantly changed. CONCLUSIONS In addition to decreasing serum phosphate levels, various beneficial effects on clinical and laboratory parameters of phosphate lowering agents might play potential roles in diminishing morbidity and mortality in CKD patients.
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Affiliation(s)
- Jeerath Phannajit
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, 1873 RAMA IV, Bangkok, 10330, Thailand.,Division of Clinical Epidemiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Research Unit for Metabolic Bone Disease in CKD Patients, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Natthaphon Wonghakaeo
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, 1873 RAMA IV, Bangkok, 10330, Thailand
| | - Kullaya Takkavatakarn
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, 1873 RAMA IV, Bangkok, 10330, Thailand
| | - Thanin Asawavichienjinda
- Division of Clinical Epidemiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kearkiat Praditpornsilpa
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, 1873 RAMA IV, Bangkok, 10330, Thailand
| | - Somchai Eiam-Ong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, 1873 RAMA IV, Bangkok, 10330, Thailand
| | - Paweena Susantitaphong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, 1873 RAMA IV, Bangkok, 10330, Thailand. .,Research Unit for Metabolic Bone Disease in CKD Patients, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
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14
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Bover J, Aguilar A, Arana C, Molina P, Lloret MJ, Ochoa J, Berná G, Gutiérrez-Maza YG, Rodrigues N, D'Marco L, Górriz JL. Clinical Approach to Vascular Calcification in Patients With Non-dialysis Dependent Chronic Kidney Disease: Mineral-Bone Disorder-Related Aspects. Front Med (Lausanne) 2021; 8:642718. [PMID: 34095165 PMCID: PMC8171667 DOI: 10.3389/fmed.2021.642718] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 04/12/2021] [Indexed: 12/13/2022] Open
Abstract
Chronic kidney disease (CKD) is associated with a very high morbimortality, mainly from cardiovascular origin, and CKD is currently considered in the high- or very high risk- cardiovascular risk category. CKD-mineral and bone disorders (CKD-MBDs), including vascular and/or valvular calcifications, are also associated with these poor outcomes. Vascular calcification (VC) is very prevalent (both intimal and medial), even in non-dialysis dependent patients, with a greater severity and more rapid progression. Simple X-ray based-scores such as Adragão's (AS) are useful prognostic tools and AS (even AS based on hand-X-ray only) may be superior to the classic Kauppila's score when evaluating non-dialysis CKD patients. Thus, in this mini-review, we briefly review CKD-MBD-related aspects of VC and its complex pathophysiology including the vast array of contributors and inhibitors. Furthermore, although VC is a surrogate marker and is not yet considered a treatment target, we consider that the presence of VC may be relevant in guiding therapeutic interventions, unless all patients are treated with the mindset of reducing the incidence or progression of VC with the currently available armamentarium. Avoiding phosphate loading, restricting calcium-based phosphate binders and high doses of vitamin D, and avoiding normalizing (within the normal limits for the assay) parathyroid hormone levels seem logical approaches. The availability of new drugs and future studies, including patients in early stages of CKD, may lead to significant improvements not only in patient risk stratification but also in attenuating the accelerated progression of VC in CKD.
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Affiliation(s)
- Jordi Bover
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, Universitat Autònoma, REDinREN, Barcelona, Spain
| | - Armando Aguilar
- Department of Nephrology, Instituto Mexicano del Seguro Social, Hospital General de Zona No. 2, Tuxtla Gutiérrez, Mexico
| | - Carolt Arana
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, Universitat Autònoma, REDinREN, Barcelona, Spain
| | - Pablo Molina
- Department of Nephrology, Hospital Universitario Dr Peset, Universidad de Valencia, REDinREN, Valencia, Spain
| | - María Jesús Lloret
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, Universitat Autònoma, REDinREN, Barcelona, Spain
| | - Jackson Ochoa
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, Universitat Autònoma, REDinREN, Barcelona, Spain
| | - Gerson Berná
- Department of Nephrology, Fundació Puigvert, IIB Sant Pau, Universitat Autònoma, REDinREN, Barcelona, Spain
| | - Yessica G Gutiérrez-Maza
- Department of Nephrology, Instituto Mexicano del Seguro Social, Hospital General de Zona No. 2, Tuxtla Gutiérrez, Mexico
| | - Natacha Rodrigues
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Universitário Lisboa Norte, EPE, Lisboa, Portugal
| | - Luis D'Marco
- Servicio de Nefrología, Hospital Clínico Universitario, INCLIVA, Universidad de Valencia, Valencia, Spain
| | - José L Górriz
- Servicio de Nefrología, Hospital Clínico Universitario, INCLIVA, Universidad de Valencia, Valencia, Spain
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15
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Zhao L, Wang S, Liu H, Du X, Bu R, Li B, Han R, Gao J, Liu Y, Hao J, Zhao J, Meng Y, Li G. The Pharmacological Effect and Mechanism of Lanthanum Hydroxide on Vascular Calcification Caused by Chronic Renal Failure Hyperphosphatemia. Front Cell Dev Biol 2021; 9:639127. [PMID: 33928079 PMCID: PMC8076751 DOI: 10.3389/fcell.2021.639127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 03/24/2021] [Indexed: 12/03/2022] Open
Abstract
Objective The present work aimed to explore the efficacy of lanthanum hydroxide in managing the vascular calcification induced by hyperphosphate in chronic renal failure (CRF) as well as the underlying mechanism. Methods Rats were randomly allocated to five groups: normal diet control, CKD hyperphosphatemia model, CKD model treated with lanthanum hydroxide, CKD model receiving lanthanum carbonate treatment, together with CKD model receiving calcium carbonate treatment. The serum biochemical and kidney histopathological parameters were analyzed. The aortic vessels were subjected to Von Kossa staining, CT scan and proteomic analysis. In vitro, the calcium content and ALP activity were measured, and RT-PCR (SM22α, Runx2, BMP-2, and TRAF6) and Western blot (SM22α, Runx2, BMP-2, TRAF6, and NF-κB) were performed. Results In the lanthanum hydroxide group, serum biochemical and kidney histopathological parameters were significantly improved compared with the model group, indicating the efficacy of lanthanum hydroxide in postponing CRF progression and in protecting renal function. In addition, applying lanthanum hydroxide postponed hyperphosphatemia-mediated vascular calcification in CKD. Furthermore, lanthanum hydroxide was found to mitigate vascular calcification via the NF-κB signal transduction pathway. For the cultured VSMCs, lanthanum chloride (LaCl3) alleviated phosphate-mediated calcification and suppressed the activation of NF-κB as well as osteo-/chondrogenic signal transduction. Lanthanum hydroxide evidently downregulated NF-κB, BMP-2, Runx2, and TRAF6 expression. Conclusion Lanthanum hydroxide protects against renal failure and reduces the phosphorus level in serum to postpone vascular calcification progression.
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Affiliation(s)
- Lulu Zhao
- Department of Pharmacology, College of Pharmacy, Inner Mongolia Medical University, Jinshan Development, Hohhot, China
| | - Shengnan Wang
- Department of Pharmacology, College of Pharmacy, Inner Mongolia Medical University, Jinshan Development, Hohhot, China
| | - Hong Liu
- Department of Pharmacology, College of Pharmacy, Inner Mongolia Medical University, Jinshan Development, Hohhot, China
| | - Xiaoli Du
- Department of Pharmacology, College of Pharmacy, Inner Mongolia Medical University, Jinshan Development, Hohhot, China
| | - Ren Bu
- Department of Pharmacology, College of Pharmacy, Inner Mongolia Medical University, Jinshan Development, Hohhot, China
| | - Bing Li
- Department of Pharmacology, College of Pharmacy, Inner Mongolia Medical University, Jinshan Development, Hohhot, China
| | - Ruilan Han
- Department of Pharmacology, College of Pharmacy, Inner Mongolia Medical University, Jinshan Development, Hohhot, China
| | - Jie Gao
- Department of Pharmacology, College of Pharmacy, Inner Mongolia Medical University, Jinshan Development, Hohhot, China
| | - Yang Liu
- Department of Pharmacology, College of Pharmacy, Inner Mongolia Medical University, Jinshan Development, Hohhot, China
| | - Jian Hao
- Department of Nephrology, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Jianrong Zhao
- Department of Nephrology, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Yan Meng
- Department of Nephrology, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Gang Li
- Department of Pharmacology, College of Pharmacy, Inner Mongolia Medical University, Jinshan Development, Hohhot, China
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16
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Hsu BG, Tsai JP. Vascular calcification of chronic kidney disease: A brief review. Tzu Chi Med J 2021; 33:34-41. [PMID: 33505876 PMCID: PMC7821827 DOI: 10.4103/tcmj.tcmj_36_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/13/2020] [Accepted: 06/23/2020] [Indexed: 12/29/2022] Open
Abstract
Vascular calcification (VC) is highly prevalent among patients with chronic kidney disease (CKD). There is growing evidence that there is more underlying this condition than the histological presentation of atherosclerotic plaque and arteriosclerosis and that the risk of cardiovascular disease in the context of CKD might be explained by the presence of VC. While VC has been observed in the absence of overt abnormal mineral metabolism, this association is coupled to abnormal homeostasis of minerals in patients with CKD, due to hyperphosphatemia and hypercalcemia. Furthermore, recent studies have shown that the differentiation of vascular smooth muscle cells into an osteogenic phenotype is highly regulated by pro-calcifying and anti-calcifying factors. There are several imaging modalities currently used in clinical practice to evaluate the extent and severity of VC; each has different advantages and limitations. Although there is no universally accepted method for the treatment of VC, there is growing evidence of the beneficial effects of medical therapy for the condition. This study discusses the mechanism underlying VC, imaging modalities used for evaluation of the condition, and possible treatments.
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Affiliation(s)
- Bang-Gee Hsu
- School of Medicine, Tzu Chi University, Hualien, Taiwan.,Division of Nephrology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Jen-Pi Tsai
- School of Medicine, Tzu Chi University, Hualien, Taiwan.,Division of Nephrology, Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
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17
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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] [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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18
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Neven E, Corremans R, Vervaet BA, Funk F, Walpen S, Behets GJ, D’Haese PC, Verhulst A. Renoprotective effects of sucroferric oxyhydroxide in a rat model of chronic renal failure. Nephrol Dial Transplant 2020; 35:1689-1699. [PMID: 33022710 PMCID: PMC7538237 DOI: 10.1093/ndt/gfaa080] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 03/14/2020] [Indexed: 12/15/2022] Open
Abstract
Introduction Sucroferric oxyhydroxide (PA21) is an efficacious, well-tolerated iron-based phosphate binder and a promising alternative to existing compounds. We compared the effects of PA21 with those of a conventional phosphate binder on renal function, mineral homeostasis and vascular calcification in a chronic kidney disease–mineral and bone disorder (CKD-MBD) rat model. Methods To induce stable renal failure, rats were administered a 0.25% adenine diet for 8 weeks. Concomitantly, rats were treated with vehicle, 2.5 g/kg/day PA21, 5.0 g/kg/day PA21 or 3.0 g/kg/day calcium carbonate (CaCO3). Renal function and calcium/phosphorus/iron metabolism were evaluated during the study course. Renal fibrosis, inflammation, vascular calcifications and bone histomorphometry were quantified. Results Rats treated with 2.5 or 5.0 g/kg/day PA21 showed significantly lower serum creatinine and phosphorus and higher ionized calcium levels after 8 weeks of treatment compared with vehicle-treated rats. The better preserved renal function with PA21 went along with less severe anaemia, which was not observed with CaCO3. Both PA21 doses, in contrast to CaCO3, prevented a dramatic increase in fibroblast growth factor (FGF)-23 and significantly reduced the vascular calcium content while both compounds ameliorated CKD-related hyperparathyroid bone. Conclusions PA21 treatment prevented an increase in serum FGF-23 and had, aside from its phosphate-lowering capacity, a beneficial impact on renal function decline (as assessed by the renal creatinine clearance) and related disorders. The protective effect of this iron-based phosphate binder on the kidney in rats, together with its low pill burden in humans, led us to investigate its use in patients with impaired renal function not yet on dialysis.
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Affiliation(s)
- Ellen Neven
- Laboratory of Pathophysiology, Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium
| | - Raphaëlle Corremans
- Laboratory of Pathophysiology, Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium
| | - Benjamin A Vervaet
- Laboratory of Pathophysiology, Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium
| | - Felix Funk
- Department of Medical Affairs, Vifor (International) Ltd, Glattbrugg, Switzerland
| | - Sebastian Walpen
- Department of Medical Affairs, Vifor (International) Ltd, Glattbrugg, Switzerland
| | - Geert J Behets
- Laboratory of Pathophysiology, Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium
| | - Patrick C D’Haese
- Laboratory of Pathophysiology, Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium
| | - Anja Verhulst
- Laboratory of Pathophysiology, Department of Biomedical Sciences, University of Antwerp, Antwerp, Belgium
- Correspondence to: Patrick C. D’Haese; E-mail:
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19
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Ginsberg C, Zelnick LR, Block GA, Chertow GM, Chonchol M, Hoofnagle A, Kestenbaum B, de Boer IH. Differential effects of phosphate binders on vitamin D metabolism in chronic kidney disease. Nephrol Dial Transplant 2020; 35:616-623. [PMID: 32160298 DOI: 10.1093/ndt/gfaa010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/25/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Phosphate binders are commonly used in the treatment of patients with hyperphosphatemia. While phosphate binders are used to lower phosphate, the effects of specific phosphate binder types on vitamin D metabolism are unknown. METHODS We performed a secondary analysis of the Phosphate Normalization Trial in which patients with moderate to advanced chronic kidney disease were randomized to receive either placebo, sevelamer carbonate, lanthanum carbonate or calcium acetate for 9 months. We evaluated changes in serum concentrations of vitamin D metabolites including 24,25-dihydroxyvitamin D3 [24,25(OH)2D3], 1,25-dihydroxyvitamin D3 [1,25(OH)2D3], the ratio of 24,25(OH)2D3 to 25-hydroxyvitamin D [the vitamin D metabolite ratio (VMR)] and the ratio of serum 1,25(OH)2D to 25-hydroxyvitamin D. RESULTS Compared with placebo, randomization to the calcium acetate arm was associated with a 0.6 ng/mL (95% CI 0.2, 1) and 13.5 pg/ng (95% CI 5.5, 21.5) increase in 24,25(OH)2D and VMR, respectively, and a 5.2 pg/mL (95% CI 1.1, 9.4) reduction in 1,25(OH)2D. Randomization to sevelamer carbonate was associated with a 0.5 ng/mL (95% CI -0.9, -0.1) and 11.8 pg/ng (95% CI -20, -3.5) reduction in 24,25(OH)2D3 and VMR, respectively. There was no association of the sevelamer arm with the change in 1,25(OH)2D3, and randomization to lanthanum carbonate was not associated with a change in any of the vitamin D metabolites. CONCLUSION Administration of different phosphate binders to patients with moderate to severe CKD results in unique changes in vitamin D metabolism.
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Affiliation(s)
- Charles Ginsberg
- Division of Nephrology-Hypertension, University of California, San Diego, San Diego, CA, USA.,Division of Nephrology, Nephrology Section, Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
| | - Leila R Zelnick
- Division of Nephrology and Kidney Research Institute, University of Washington, Seattle, WA, USA
| | | | - Glenn M Chertow
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Michel Chonchol
- Division of Renal Diseases and Hypertension, University of Anschutz Medical Center, Aurora, CO, USA
| | - Andrew Hoofnagle
- Department of Laboratory Medicine, University of Washington, Seattle, WA, USA
| | - Bryan Kestenbaum
- Division of Nephrology and Kidney Research Institute, University of Washington, Seattle, WA, USA
| | - Ian H de Boer
- Division of Nephrology and Kidney Research Institute, University of Washington, Seattle, WA, USA.,VA Puget Sound Health Care System, Seattle, WA, USA
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20
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Lambert O, Couchoud C, Metzger M, Choukroun G, Jacquelinet C, Mercadal L. Effects of the dialysate calcium concentrations and mineral bone disease treatments on mortality in The French Renal Epidemiology and Information Network (REIN) registry. PLoS One 2020; 15:e0235135. [PMID: 32628733 PMCID: PMC7337343 DOI: 10.1371/journal.pone.0235135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 06/09/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In patients on hemodialysis (HD), the various chemical elements in the dialysate may influence survival rates. In particular, calcium modifies mineral and bone metabolism and the vascular calcification rate. We studied the influence of the dialysate calcium concentration and the treatments prescribed for mineral bone disease (MBD) on survival. METHODS All patients in REIN having initiated HD from 2010 to 2013 were classified according to their exposure to the different dialysate calcium concentrations in their dialysis unit. Data on the individual patients' treatments for MBD were extracted from the French national health database. Cox proportional hazard models were used to estimate mortality hazard ratios (HR) associated with time-dependent exposure to dialysate calcium concentrations and MBD therapies, adjusted for comorbidities, laboratory and technical data. RESULTS Dialysate calcium concentration of 1.5 mmol/L was used by 81% of the dialysis centers in 2010 and in 83% in 2014. Most centers were using several formulas in up to 78% for 3 formulas in 2010 to 86% in 2014. In full adjusted Cox survival analyses, the percentage of calcium >1.5 mmol/L and <1.5 mmol/l by center and the number of formula used per center were not associated with survival. Depending on the daily dose used, the MBD therapies were associated with survival improvement for calcium, native vitamin D, active vitamin D, sevelamer, lanthanum and cinacalcet in the second and third tertiles of dose. CONCLUSION No influence of the dialysate calcium concentration was evidenced on survival whereas all MBD therapies were associated with a survival improvement depending on the daily dose used.
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Affiliation(s)
- Oriane Lambert
- CESP, Centre for Research in Epidemiology and Population Health, Univ Paris-Saclay, Univ Paris Sud, UVSQ, INSERM UMRS, Villejuif, France
| | | | - Marie Metzger
- CESP, Centre for Research in Epidemiology and Population Health, Univ Paris-Saclay, Univ Paris Sud, UVSQ, INSERM UMRS, Villejuif, France
| | - Gabriel Choukroun
- Nephrology, Dialysis & Transplantation Department, CHU Amiens, INSERM UMR, Jules Verne University of Picardie, Amiens, France
| | - Christian Jacquelinet
- CESP, Centre for Research in Epidemiology and Population Health, Univ Paris-Saclay, Univ Paris Sud, UVSQ, INSERM UMRS, Villejuif, France
| | - Lucile Mercadal
- CESP, Centre for Research in Epidemiology and Population Health, Univ Paris-Saclay, Univ Paris Sud, UVSQ, INSERM UMRS, Villejuif, France
- Nephrology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
- * E-mail:
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Data from the ERA-EDTA Registry were examined for trends in excess mortality in European adults on kidney replacement therapy. Kidney Int 2020; 98:999-1008. [PMID: 32569654 DOI: 10.1016/j.kint.2020.05.039] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 04/22/2020] [Accepted: 05/06/2020] [Indexed: 01/18/2023]
Abstract
The objective of this study was to investigate whether the improvement in survival seen in patients on kidney replacement therapy reflects the enhanced survival of the general population. Patient and general population statistics were obtained from the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry and the World Health Organization databases, respectively. Relative survival models were composed to examine trends over time in all-cause and cause-specific excess mortality, stratified by age and modality of kidney replacement therapy, and adjusted for sex, primary kidney disease and country. In total, 280,075 adult patients started kidney replacement therapy between 2002 and 2015. The excess mortality risk in these patients decreased by 16% per five years (relative excess mortality risk (RER) 0.84; 95% confidence interval 0.83-0.84). This reflected a 14% risk reduction in dialysis patients (RER 0.86; 0.85-0.86), and a 16% increase in kidney transplant recipients (RER 1.16; 1.07-1.26). Patients on dialysis showed a decrease in excess mortality risk of 28% per five years for atheromatous cardiovascular disease as the cause of death (RER 0.72; 0.70-0.74), 10% for non-atheromatous cardiovascular disease (RER 0.90; 0.88-0.92) and 10% for infections (RER 0.90; 0.87-0.92). Kidney transplant recipients showed stable excess mortality risks for most causes of death, although it did worsen in some subgroups. Thus, the increase in survival in patients on kidney replacement therapy is not only due to enhanced survival in the general population, but also due to improved survival in the patient population, primarily in dialysis patients.
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22
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Platko K, Lebeau PF, Gyulay G, Lhoták Š, MacDonald ME, Pacher G, Hyun Byun J, Boivin FJ, Igdoura SA, Cutz JC, Bridgewater D, Ingram AJ, Krepinsky JC, Austin RC. TDAG51 (T-Cell Death-Associated Gene 51) Is a Key Modulator of Vascular Calcification and Osteogenic Transdifferentiation of Arterial Smooth Muscle Cells. Arterioscler Thromb Vasc Biol 2020; 40:1664-1679. [PMID: 32434409 DOI: 10.1161/atvbaha.119.313779] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Cardiovascular disease is the primary cause of mortality in patients with chronic kidney disease. Vascular calcification (VC) in the medial layer of the vessel wall is a unique and prominent feature in patients with advanced chronic kidney disease and is now recognized as an important predictor and independent risk factor for cardiovascular and all-cause mortality in these patients. VC in chronic kidney disease is triggered by the transformation of vascular smooth muscle cells (VSMCs) into osteoblasts as a consequence of elevated circulating inorganic phosphate (Pi) levels, due to poor kidney function. The objective of our study was to investigate the role of TDAG51 (T-cell death-associated gene 51) in the development of medial VC. METHODS AND RESULTS Using primary mouse and human VSMCs, we found that TDAG51 is induced in VSMCs by Pi and is expressed in the medial layer of calcified human vessels. Furthermore, the transcriptional activity of RUNX2 (Runt-related transcription factor 2), a well-established driver of Pi-mediated VC, is reduced in TDAG51-/- VSMCs. To explain these observations, we identified that TDAG51-/- VSMCs express reduced levels of the type III sodium-dependent Pi transporter, Pit-1, a solute transporter, a solute transporter, a solute transporter responsible for cellular Pi uptake. Significantly, in response to hyperphosphatemia induced by vitamin D3, medial VC was attenuated in TDAG51-/- mice. CONCLUSIONS Our studies highlight TDAG51 as an important mediator of Pi-induced VC in VSMCs through the downregulation of Pit-1. As such, TDAG51 may represent a therapeutic target for the prevention of VC and cardiovascular disease in patients with chronic kidney disease.
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Affiliation(s)
- Khrystyna Platko
- From the Division of Nephrology, Department of Medicine (K.P., P.F.L., G.G., Š.L., M.E.M., G.P., J.H.B., A.J.I., J.C.K., R.C.A.), McMaster University, and The Research Institute of St. Joseph's Hamilton, ON, Canada
| | - Paul F Lebeau
- From the Division of Nephrology, Department of Medicine (K.P., P.F.L., G.G., Š.L., M.E.M., G.P., J.H.B., A.J.I., J.C.K., R.C.A.), McMaster University, and The Research Institute of St. Joseph's Hamilton, ON, Canada
| | - Gabriel Gyulay
- From the Division of Nephrology, Department of Medicine (K.P., P.F.L., G.G., Š.L., M.E.M., G.P., J.H.B., A.J.I., J.C.K., R.C.A.), McMaster University, and The Research Institute of St. Joseph's Hamilton, ON, Canada
| | - Šárka Lhoták
- From the Division of Nephrology, Department of Medicine (K.P., P.F.L., G.G., Š.L., M.E.M., G.P., J.H.B., A.J.I., J.C.K., R.C.A.), McMaster University, and The Research Institute of St. Joseph's Hamilton, ON, Canada
| | - Melissa E MacDonald
- From the Division of Nephrology, Department of Medicine (K.P., P.F.L., G.G., Š.L., M.E.M., G.P., J.H.B., A.J.I., J.C.K., R.C.A.), McMaster University, and The Research Institute of St. Joseph's Hamilton, ON, Canada
| | - Giusepina Pacher
- From the Division of Nephrology, Department of Medicine (K.P., P.F.L., G.G., Š.L., M.E.M., G.P., J.H.B., A.J.I., J.C.K., R.C.A.), McMaster University, and The Research Institute of St. Joseph's Hamilton, ON, Canada
| | - Jae Hyun Byun
- From the Division of Nephrology, Department of Medicine (K.P., P.F.L., G.G., Š.L., M.E.M., G.P., J.H.B., A.J.I., J.C.K., R.C.A.), McMaster University, and The Research Institute of St. Joseph's Hamilton, ON, Canada
| | - Felix J Boivin
- Department of Pathology and Molecular Medicine (F.J.B., S.A.I., D.B.), McMaster University Medical Centre, Hamilton, ON, Canada
| | - Suleiman A Igdoura
- Department of Pathology and Molecular Medicine (F.J.B., S.A.I., D.B.), McMaster University Medical Centre, Hamilton, ON, Canada.,Department of Biology (S.A.I.), McMaster University Medical Centre, Hamilton, ON, Canada
| | - Jean-Claude Cutz
- Department of Pathology and Molecular Medicine (J.-C.C.), McMaster University, and The Research Institute of St. Joseph's Hamilton, ON, Canada
| | - Darren Bridgewater
- Department of Pathology and Molecular Medicine (F.J.B., S.A.I., D.B.), McMaster University Medical Centre, Hamilton, ON, Canada
| | - Alistair J Ingram
- From the Division of Nephrology, Department of Medicine (K.P., P.F.L., G.G., Š.L., M.E.M., G.P., J.H.B., A.J.I., J.C.K., R.C.A.), McMaster University, and The Research Institute of St. Joseph's Hamilton, ON, Canada
| | - Joan C Krepinsky
- From the Division of Nephrology, Department of Medicine (K.P., P.F.L., G.G., Š.L., M.E.M., G.P., J.H.B., A.J.I., J.C.K., R.C.A.), McMaster University, and The Research Institute of St. Joseph's Hamilton, ON, Canada
| | - Richard C Austin
- From the Division of Nephrology, Department of Medicine (K.P., P.F.L., G.G., Š.L., M.E.M., G.P., J.H.B., A.J.I., J.C.K., R.C.A.), McMaster University, and The Research Institute of St. Joseph's Hamilton, ON, Canada
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Lamarche MC, Hopman WM, Garland JS, White CA, Holden RM. Relationship of coronary artery calcification with renal function decline and mortality in predialysis chronic kidney disease patients. Nephrol Dial Transplant 2020; 34:1715-1722. [PMID: 30010904 DOI: 10.1093/ndt/gfy183] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 05/11/2018] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) have higher levels of coronary artery calcification (CAC) compared with the general population. The role of CAC in renal function decline is not well understood. METHODS In this prospective cohort study of Stages 3-5 CKD patients with CAC scores kidney function decline, development of end-stage kidney disease (ESKD) and all-cause mortality were determined at 5 and 10 years. Baseline variables included markers of CKD and chronic kidney disease mineral and bone disorder (CKD-MBD), demographics and comorbidities. Multivariable analyses identified predictors of outcomes, and survival curves demonstrated the association of CAC score with ESKD and mortality. RESULTS One hundred and seventy-eight patients were enrolled between 2005 and 2007. Independent predictors of ESKD at 5 years were estimated glomerular filtration rate (eGFR) and urine albumin-creatinine ratio (UACR); at 10 years, eGFR was no longer a predictor, but CAC was now significant. Those who developed ESKD at the fastest rate either had the highest CAC score (≥400 AU) or were youngest and had the lowest calcidiol, and highest serum phosphate, UACR and percentage change in CAC per year. Predictors of eGFR decline over 5 years were UACR, parathyroid hormone and CAC score. Predictors of mortality at 5 years were age, diabetes and eGFR and at 10 years also included CAC score. CONCLUSIONS In Stages 3-5 CKD patients, CAC is an independent predictor of both ESKD and mortality at 10 years. Those who developed ESKD at the fastest rate either had the highest CAC score or the worst CKD-MBD derangements.
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Affiliation(s)
| | - Wilma M Hopman
- Clinical Research Centre, Kingston Health Sciences Centre, Kingston, ON, Canada.,Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | | | | | - Rachel M Holden
- Department of Medicine, Queen's University, Kingston, ON, Canada
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24
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Drüeke TB, Massy ZA. Vascular calcification-any place left for nicotinamide? Nephrol Dial Transplant 2020; 35:18-22. [PMID: 31071218 DOI: 10.1093/ndt/gfz057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 03/06/2019] [Indexed: 12/12/2022] Open
Affiliation(s)
- Tilman B Drüeke
- Inserm U-1018, Team 5, CESP, Versailles Saint-Quentin-en-Yvelines University (Paris-Ile-de-France-Ouest University, UVSQ), Paris-Sud University (UPS), and Paris Saclay University, Villejuif, France
| | - Ziad A Massy
- Inserm U-1018, Team 5, CESP, Versailles Saint-Quentin-en-Yvelines University (Paris-Ile-de-France-Ouest University, UVSQ), Paris-Sud University (UPS), and Paris Saclay University, Villejuif, France.,Division of Nephrology, Ambroise Paré Hospital, APHP, Boulogne-Billancourt, Paris, France
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25
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Neto R, Frazão J. Efficacy and safety of calcium carbonate in normophosphataemic patients with chronic kidney disease Stages 3 and 4. Clin Kidney J 2019; 14:550-555. [PMID: 33623678 PMCID: PMC7886574 DOI: 10.1093/ckj/sfz181] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 11/08/2019] [Indexed: 11/12/2022] Open
Abstract
Background Disordered bone and mineral metabolism are a common complication of chronic kidney disease (CKD). Phosphate binders are often prescribed in advanced CKD, when hyperphosphataemia develops. Little is known about the role of these drugs in earlier stages, when serum phosphorus levels are kept in the normal range by increased urinary excretion. Methods A retrospective, controlled observational study was conducted on a cohort of 78 pre-dialysis patients. Subjects had CKD Stage 3 or 4, normal serum phosphorus levels and increased urinary fractional excretion of phosphate. Thirty-eight patients receiving calcium carbonate for 24 months were compared with 40 patients under no phosphate binders, regarding mineral metabolism parameters and vascular calcification scores. Results Calcium carbonate decreased mean urinary fractional excretion of phosphate and median 24-h urine phosphorus, whereas no significant change was seen in the control group. Mean serum phosphorus and median serum intact parathyroid hormone (iPTH) remained stable in treated patients but increased in the control group. Vascular calcification, assessed by Kauppila and Adragão scores, worsened under calcium carbonate with no significant change in the control group. Conclusions Calcium carbonate reduced urinary phosphate excretion and prevented the rise in phosphorus and iPTH serum levels in a cohort of normophosphataemic pre-dialysis patients. However, treatment was associated with increased vascular calcification, suggesting that calcium-based phosphate binders are not a safe option for CKD patients.
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Affiliation(s)
- Ricardo Neto
- Nephrology and Infectious Diseases Research and Development Group, INEB-(I3S), University of Porto, Porto, Portugal.,Department of Medicine, Porto Medical School, University of Porto, Porto, Portugal.,Department of Nephrology, Centro Hospitalar Universitário São João, Porto, Portugal
| | - João Frazão
- Nephrology and Infectious Diseases Research and Development Group, INEB-(I3S), University of Porto, Porto, Portugal.,Department of Medicine, Porto Medical School, University of Porto, Porto, Portugal.,Department of Nephrology, Centro Hospitalar Universitário São João, Porto, Portugal
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26
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Kakani E, Elyamny M, Ayach T, El‐Husseini A. Pathogenesis and management of vascular calcification in CKD and dialysis patients. Semin Dial 2019; 32:553-561. [DOI: 10.1111/sdi.12840] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Elijah Kakani
- Division of Hospital Medicine University of Kentucky Lexington KY USA
| | - Mohamed Elyamny
- Division of Nephrology, Bone and Mineral Metabolism University of Kentucky Lexington KY USA
| | - Taha Ayach
- Division of Nephrology, Bone and Mineral Metabolism University of Kentucky Lexington KY USA
| | - Amr El‐Husseini
- Division of Nephrology, Bone and Mineral Metabolism University of Kentucky Lexington KY USA
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27
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Ruggiero B, Trillini M, Tartaglione L, Rotondi S, Perticucci E, Tripepi R, Aparicio C, Lecchi V, Perna A, Peraro F, Villa D, Ferrari S, Cannata A, Mazzaferro S, Mallamaci F, Zoccali C, Bellasi A, Cozzolino M, Remuzzi G, Ruggenenti P, Kohan DE. Effects of Sevelamer Carbonate in Patients With CKD and Proteinuria: The ANSWER Randomized Trial. Am J Kidney Dis 2019; 74:338-350. [PMID: 31027883 DOI: 10.1053/j.ajkd.2019.01.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 01/29/2019] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Hyperphosphatemia is associated with increased risk for chronic kidney disease (CKD) progression and reduced antiproteinuric effects of renin-angiotensin system (RAS) blockers. We investigated whether the phosphate binder sevelamer carbonate may enhance the antiproteinuric effect of RAS inhibitors in patients with CKD. STUDY DESIGN Phase 2, randomized, controlled, open-label, crossover trial. SETTING & PARTICIPANTS Between November 2013 and December 2014, we enrolled 53 patients with CKD with estimated glomerular filtration rates (eGFRs)>15mL/min/1.73m2 and residual proteinuria with protein excretion≥0.5g/24h despite maximal tolerated ramipril and/or irbesartan therapy from 2 nephrology units in Italy. INTERVENTION After stratification by serum phosphate level, ≤4 or>4mg/dL, patients were randomly assigned to 3 months of sevelamer (1,600mg thrice daily) treatment followed by 3 months without sevelamer separated by a 1-month washout period or 3 months without sevelamer followed by 3 months with sevelamer, also separated by a 1-month washout period. OUTCOMES The primary outcome was 24-hour proteinuria (n=49patients). Secondary outcomes included measured GFR (using iohexol plasma clearance), office blood pressure (BP), serum lipid levels, levels of inflammation and bone metabolism biomarkers, urinary electrolyte levels, and arterial stiffness. RESULTS Changes in proteinuria during the 3-month treatment with (from 1.36 [IQR, 0.77-2.51] to 1.36 [IQR, 0.77-2.60] g/24h) or without (from 1.36 [IQR, 0.99-2.38] to 1.48 [IQR, 0.81-2.77] g/24h) sevelamer were similar (P=0.1). Sevelamer reduced urinary phosphate excretion without affecting serum phosphate levels. Sevelamer reduced C-reactive protein (CRP), glycated hemoglobin, and total and low-density lipoprotein cholesterol levels and increased high-density lipoprotein cholesterol levels without affecting levels of office BP, measured GFR, fibroblast growth factor 23, klotho, intact parathyroid hormone, serum vitamin D, or other urinary electrolytes. Results were similar in the low- and high-phosphate groups. Sevelamer was well tolerated. Adverse events were comparable between treatment periods. One case of transient hypophosphatemia was observed during treatment with sevelamer. LIMITATIONS Short treatment duration, lower pretreatment proteinuria than expected. CONCLUSIONS 3-month sevelamer treatment did not reduce proteinuria in patients with CKD on maximal RAS blockade. Amelioration of inflammation and dyslipidemia with sevelamer treatment raises the possibility that it may confer benefit in patients with CKD beyond reduction of proteinuria. FUNDING Sanofi (Milan, Italy). TRIAL REGISTRATION Registered at ClinicalTrials.gov with study number NCT01968759.
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Affiliation(s)
- Barbara Ruggiero
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Matias Trillini
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Lida Tartaglione
- Department of Cardiovascular, Respiratory, Nephrologic, Anesthetic and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Silverio Rotondi
- Department of Cardiovascular, Respiratory, Nephrologic, Anesthetic and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Elena Perticucci
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Rocco Tripepi
- Bianchi-Melacrino-Morelli Hospital, Nephrology Unit, Reggio Calabria, Italy
| | - Carolina Aparicio
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Veruska Lecchi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Annalisa Perna
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Francesco Peraro
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Davide Villa
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Silvia Ferrari
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Antonio Cannata
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Sandro Mazzaferro
- Department of Cardiovascular, Respiratory, Nephrologic, Anesthetic and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Carmine Zoccali
- Bianchi-Melacrino-Morelli Hospital, Nephrology Unit, Reggio Calabria, Italy
| | - Antonio Bellasi
- Department of Nephrology and Dialysis, Sant'Anna Hospital, ASST-Lariana, Como, Italy
| | | | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy; L. Sacco Department of Biomedical and Clinical Sciences, University of Milan, Italy.
| | - Piero Ruggenenti
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy; Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Donald E Kohan
- Division of Nephrology, University of Utah Health Sciences Center, Salt Lake City, UT
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CKD, arterial calcification, atherosclerosis and bone health: Inter-relationships and controversies. Atherosclerosis 2018; 278:49-59. [DOI: 10.1016/j.atherosclerosis.2018.08.046] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 07/12/2018] [Accepted: 08/29/2018] [Indexed: 01/14/2023]
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Cost-Effectiveness Analysis for the Treatment of Hyperphosphatemia in Predialysis Patients: Calcium-Based versus Noncalcium-Based Phosphate Binders. Int J Nephrol 2018; 2018:2138528. [PMID: 30327732 PMCID: PMC6169205 DOI: 10.1155/2018/2138528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 09/02/2018] [Indexed: 11/18/2022] Open
Abstract
Background Hyperphosphatemia in chronic kidney disease (CKD) patients is often treated with calcium carbonate (CaCO3) despite the fact that CaCO3 is associated with increased calcium load and potentially increased cardiovascular risk. Alternative treatments with noncalcium-based phosphate binders do not increase the calcium load but are more costly. This study analyzes the cost-effectiveness of sevelamer versus CaCO3 for the treatment of hyperphosphatemia in stage III-V predialysis CKD patients in Malaysia. Methods A Markov decision model was adapted to simulate a hypothetical cohort of CKD patients requiring treatment for hyperphosphatemia. Survival was estimated by using efficacy data from the INDEPENDENT-CKD clinical trial. Cost data was obtained from Malaysian studies while health state utilities were derived from literature. Analysis was performed over lifetime duration from the perspective of the Ministry of Health Malaysia with 2013 as reference year. Results In the base case analysis, sevelamer treatment gained 6.37 life years (5.27 QALY) compared to 4.25 life years (3.54 QALY) with CaCO3. At 3% discount, lifetime costs were RM159,901 ($48,750) and RM77,139 ($23,518) on sevelamer and CaCO3, respectively. Incremental cost-effectiveness (ICER) of sevelamer versus CaCO3 was RM47,679 ($14,536) per QALY, which is less than the WHO threshold of three times GDP per capita (RM99,395) per QALY. Sensitivity analyses, both using scenario sensitivity analysis and probabilistic sensitivity analysis, showed the result to be robust. Conclusions Our study finds that sevelamer is potentially cost-effective compared to CaCO3, for the treatment of hyperphosphatemia in predialysis CKD III-V. We propose that sevelamer should be an option in the treatment of Malaysian predialysis patients with hyperphosphatemia, particularly those with high calcium load.
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Ruospo M, Palmer SC, Natale P, Craig JC, Vecchio M, Elder GJ, Strippoli GFM. Phosphate binders for preventing and treating chronic kidney disease-mineral and bone disorder (CKD-MBD). Cochrane Database Syst Rev 2018; 8:CD006023. [PMID: 30132304 PMCID: PMC6513594 DOI: 10.1002/14651858.cd006023.pub3] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Phosphate binders are used to reduce positive phosphate balance and to lower serum phosphate levels for people with chronic kidney disease (CKD) with the aim to prevent progression of chronic kidney disease-mineral and bone disorder (CKD-MBD). This is an update of a review first published in 2011. OBJECTIVES The aim of this review was to assess the benefits and harms of phosphate binders for people with CKD with particular reference to relevant biochemical end-points, musculoskeletal and cardiovascular morbidity, hospitalisation, and death. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 12 July 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials (RCTs) or quasi-RCTs of adults with CKD of any GFR category comparing a phosphate binder to another phosphate binder, placebo or usual care to lower serum phosphate. Outcomes included all-cause and cardiovascular death, myocardial infarction, stroke, adverse events, vascular calcification and bone fracture, and surrogates for such outcomes including serum phosphate, parathyroid hormone (PTH), and FGF23. DATA COLLECTION AND ANALYSIS Two authors independently selected studies for inclusion and extracted study data. We applied the Cochrane 'Risk of Bias' tool and used the GRADE process to assess evidence certainty. We estimated treatment effects using random-effects meta-analysis. Results were expressed as risk ratios (RR) for dichotomous outcomes together with 95% confidence intervals (CI) or mean differences (MD) or standardised MD (SMD) for continuous outcomes. MAIN RESULTS We included 104 studies involving 13,744 adults. Sixty-nine new studies were added to this 2018 update.Most placebo or usual care controlled studies were among participants with CKD G2 to G5 not requiring dialysis (15/25 studies involving 1467 participants) while most head to head studies involved participants with CKD G5D treated with dialysis (74/81 studies involving 10,364 participants). Overall, seven studies compared sevelamer with placebo or usual care (667 participants), seven compared lanthanum to placebo or usual care (515 participants), three compared iron to placebo or usual care (422 participants), and four compared calcium to placebo or usual care (278 participants). Thirty studies compared sevelamer to calcium (5424 participants), and fourteen studies compared lanthanum to calcium (1690 participants). No study compared iron-based binders to calcium. The remaining studies evaluated comparisons between sevelamer (hydrochloride or carbonate), sevelamer plus calcium, lanthanum, iron (ferric citrate, sucroferric oxyhydroxide, stabilised polynuclear iron(III)-oxyhydroxide), calcium (acetate, ketoglutarate, carbonate), bixalomer, colestilan, magnesium (carbonate), magnesium plus calcium, aluminium hydroxide, sucralfate, the inhibitor of phosphate absorption nicotinamide, placebo, or usual care without binder. In 82 studies, treatment was evaluated among adults with CKD G5D treated with haemodialysis or peritoneal dialysis, while in 22 studies, treatment was evaluated among participants with CKD G2 to G5. The duration of study follow-up ranged from 8 weeks to 36 months (median 3.7 months). The sample size ranged from 8 to 2103 participants (median 69). The mean age ranged between 42.6 and 68.9 years.Random sequence generation and allocation concealment were low risk in 25 and 15 studies, respectively. Twenty-seven studies reported low risk methods for blinding of participants, investigators, and outcome assessors. Thirty-one studies were at low risk of attrition bias and 69 studies were at low risk of selective reporting bias.In CKD G2 to G5, compared with placebo or usual care, sevelamer, lanthanum, iron and calcium-based phosphate binders had uncertain or inestimable effects on death (all causes), cardiovascular death, myocardial infarction, stroke, fracture, or coronary artery calcification. Sevelamer may lead to constipation (RR 6.92, CI 2.24 to 21.4; low certainty) and lanthanum (RR 2.98, CI 1.21 to 7.30, moderate certainty) and iron-based binders (RR 2.66, CI 1.15 to 6.12, moderate certainty) probably increased constipation compared with placebo or usual care. Lanthanum may result in vomiting (RR 3.72, CI 1.36 to 10.18, low certainty). Iron-based binders probably result in diarrhoea (RR 2.81, CI 1.18 to 6.68, high certainty), while the risks of other adverse events for all binders were uncertain.In CKD G5D sevelamer may lead to lower death (all causes) (RR 0.53, CI 0.30 to 0.91, low certainty) and induce less hypercalcaemia (RR 0.30, CI 0.20 to 0.43, low certainty) when compared with calcium-based binders, and has uncertain or inestimable effects on cardiovascular death, myocardial infarction, stroke, fracture, or coronary artery calcification. The finding of lower death with sevelamer compared with calcium was present when the analysis was restricted to studies at low risk of bias (RR 0.50, CI 0.32 to 0.77). In absolute terms, sevelamer may lower risk of death (all causes) from 210 per 1000 to 105 per 1000 over a follow-up of up to 36 months, compared to calcium-based binders. Compared with calcium-based binders, lanthanum had uncertain effects with respect to all-cause or cardiovascular death, myocardial infarction, stroke, fracture, or coronary artery calcification and probably had reduced risks of treatment-related hypercalcaemia (RR 0.16, CI 0.06 to 0.43, low certainty). There were no head-to-head studies of iron-based binders compared with calcium. The paucity of placebo-controlled studies in CKD G5D has led to uncertainty about the effects of phosphate binders on patient-important outcomes compared with placebo.It is uncertain whether the effects of binders on clinically-relevant outcomes were different for patients who were and were not treated with dialysis in subgroup analyses. AUTHORS' CONCLUSIONS In studies of adults with CKD G5D treated with dialysis, sevelamer may lower death (all causes) compared to calcium-based binders and incur less treatment-related hypercalcaemia, while we found no clinically important benefits of any phosphate binder on cardiovascular death, myocardial infarction, stroke, fracture or coronary artery calcification. The effects of binders on patient-important outcomes compared to placebo are uncertain. In patients with CKD G2 to G5, the effects of sevelamer, lanthanum, and iron-based phosphate binders on cardiovascular, vascular calcification, and bone outcomes compared to placebo or usual care, are also uncertain and they may incur constipation, while iron-based binders may lead to diarrhoea.
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Affiliation(s)
| | - Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Patrizia Natale
- DiaverumMedical Scientific OfficeLundSweden
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
| | - Jonathan C Craig
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- Flinders UniversityCollege of Medicine and Public HealthAdelaideSAAustralia5001
| | | | - Grahame J Elder
- Westmead HospitalDepartment of Renal MedicineWestmeadNSWAustralia2145
- Garvan Institute of Medical ResearchOsteoporosis and Bone Biology DivisionDarlinghurstNSWAustralia2010
| | - Giovanni FM Strippoli
- DiaverumMedical Scientific OfficeLundSweden
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- Diaverum AcademyBariItaly
- The University of SydneySydney School of Public HealthSydneyAustralia
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Use of phosphate-binders and risk of infection-related and all-cause mortality in patients undergoing hemodialysis: The Q-Cohort Study. Sci Rep 2018; 8:11387. [PMID: 30061632 PMCID: PMC6065422 DOI: 10.1038/s41598-018-29757-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 07/13/2018] [Indexed: 12/13/2022] Open
Abstract
The use of phosphate (P)-binders allows hemodialysis patients to take in more protein and thus may maintain a good nutritional status. Protein-energy-malnutrition increases the risk of infection-related death. The association between use of P-binders and the relative risks of infection-related death remains unknown in hemodialysis patients. A total of 2926 hemodialysis patients registered to the Q-Cohort Study was followed up for 4-years. The association between use of P-binders and the risks for infection-related and all-cause mortality were estimated by Cox proportional hazards risk model with multiple adjustments by conventional and propensity-score based approaches. During the follow-up period, 106 patients and 492 patients died of infection and any cause, respectively. Cox proportional hazards models with multivariable adjustments including nutritional confounders showed that the incidence of infection-related death was significantly lower in patients with P-binders use compared with those without (hazard ratio [95% confidence interval] for infection-related mortality 0.63 [0.40-0.99]). The results remained significant even after applying four different propensity score-based analyses. Notably, use of P-binders was associated with a lower risk of all-cause mortality. Further studies including randomized controlled clinical trials and observational studies analyzed by an instrumental variable model will provide more robust evidences for the associations observed in our study.
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Abstract
PURPOSE OF REVIEW Calcium is an essential ion for the maintenance of normal bone health and physiologic functions. The extracellular and intracellular levels of calcium are maintained through hormonal regulation called homeostasis. Balance, the net intake minus excretion of calcium, is maintained by hormonal regulation of intestinal absorption and fecal/urinary excretion. Homeostasis and balance are disconnected in patients with chronic kidney disease (CKD). The purpose of this review is to understand how calcium homeostasis and balance are impaired in CKD. RECENT FINDINGS Two formal calcium balance studies have found that an oral intake of 800-1000 mg of calcium in adults with CKD leads to neutral calcium balance, whereas amounts greater than that lead to positive calcium balance. In patients with CKD, the main determinant of positive calcium balance is the intake and the lack of urinary calcium excretion. SUMMARY Calcium balance is different in patients with advanced CKD compared with patients without CKD. Thus, the oral intake of calcium in the form of diet and binders should not exceed 800-1000 mg/day to achieve neutral calcium balance in adult patients with CKD stages 3b/4.
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Affiliation(s)
- Sharon M Moe
- Division of Nephrology, Indiana University School of Medicine
- Department of Medicine, Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana, USA
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Kovesdy CP, Lu JL, Wall BM, Gyamlani G, Naseer A, Wallick A, Han Z, Thomas F, Quarles LD, Jarmukli N. Changes With Lanthanum Carbonate, Calcium Acetate, and Phosphorus Restriction in CKD: A Randomized Controlled Trial. Kidney Int Rep 2018; 3:897-904. [PMID: 29989014 PMCID: PMC6035139 DOI: 10.1016/j.ekir.2018.03.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 02/27/2018] [Accepted: 03/22/2018] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Abnormal phosphorus homeostasis develops early in chronic kidney disease (CKD). It is unclear if its correction results in improved clinical outcomes in non-dialysis dependent CKD. METHODS We conducted a randomized controlled, parallel design clinical trial in 120 patients with estimated glomerular filtration rate 15 to 59 ml/min per 1.73 m2 and abnormal phosphorus homeostasis (serum phosphorus >4.6 mg/dl, parathyroid hormone [PTH] >70 pg/ml or tubular reabsorption of phosphorus [TRP] <80%). Patients were randomized to open-label lanthanum carbonate versus calcium acetate versus dietary intervention over 1 year. The co-primary outcomes were month 12 (vs. baseline) biochemical (serum phosphorus, TRP, PTH, calcium, bone-specific alkaline phosphatase [bALP], and fibroblast growth factor 23 [FGF23]) and vascular parameters (coronary artery calcium score, pulse wave velocity, and endothelial dysfunction) in all patients. Secondary outcomes were between-treatment differences in change for each parameter between month 12 and baseline. All analyses were intention to treat. RESULTS Baseline characteristics were similar in the 3 groups. A total of 107 patients (89%) completed 12 months of follow-up. Differences were not significant at month 12 (vs. baseline) for any of the outcomes except bALP (median [25th, 75th] percentile at month 12 versus baseline: 13.8 [10.6, 17.6] vs. 15.8 [12.1, 21.1], P < .001) and FGF23 (132 [99, 216] vs. 133 [86, 189], P = .002). Changes for all outcomes were similar in the 3 arms except for PTH, which was suppressed more effectively by calcium acetate (P < .001). CONCLUSION A 1-year intervention to limit phosphorus absorption using dietary restriction or 2 different phosphorus binders resulted in decreased bALP suggesting improved bone turnover, but no other significant changes in biochemical or vascular parameters in patients with CKD stage 3/4. (ClinicalTrials.gov: NCT01357317).
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Affiliation(s)
- Csaba P. Kovesdy
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Jun Ling Lu
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Barry M. Wall
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA
| | - Geeta Gyamlani
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA
| | - Adnan Naseer
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA
| | - Angela Wallick
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA
| | - Zhongji Han
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Fridtjof Thomas
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - L. Darryl Quarles
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Nabil Jarmukli
- Salem Veterans Affairs Medical Center, Salem, Virginia, USA
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Carfagna F, Del Vecchio L, Pontoriero G, Locatelli F. Current and potential treatment options for hyperphosphatemia. Expert Opin Drug Saf 2018; 17:597-607. [PMID: 29783873 DOI: 10.1080/14740338.2018.1476487] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Hyperphosphatemia is common in late stages of chronic kidney disease and is often associated with elevated parathormone levels, abnormal bone mineralization, extra-osseous calcification, and increased risk of cardiovascular events and death. Several classes of oral phosphate binders are available to help control plasma phosphorus levels. Although effective at lowering serum phosphorus, they all have safety, tolerability, and compliance issues that need to be considered when selecting which one to use. AREAS COVERED This paper reviews the most established treatment options for hyperphosphatemia, in patients with chronic kidney disease, focusing on the new inhibitors of active phosphate absorption. EXPERT OPINION The prevention and the treatment of hyperphosphatemia is today far to be satisfactory. Nonetheless, an extending range of phosphate binders are now available. Aluminum has potentially serious toxic risks. Calcium-based binders are very effective but can lead to hypercalcemia and/or positive calcium balance and progression of cardiovascular calcification. No long-term data are available for the new calcium acetate/magnesium combination product. Lanthanum is an effective phosphate binder, and long-term effects of tissue deposition seem clinically irrelevant. Sevelamer, appear to have profiles that would lead to pleiotropic effects and reduced progression of vascular calcification, and the main adverse events seen with these agents are gastrointestinal. Iron has a powerful capability of binding phosphate, thus numerous preparations are available, both with and without significant systemic absorption of the iron component. The inhibitors of active intestinal phosphate transport, with their very selective mechanism of action and low pill burden seem the most interesting approach; however, do not seem at present to be effective alone, in reducing serum phosphorus levels.
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Affiliation(s)
- Fabio Carfagna
- a Department of Nephrology and Dialysis , A. Manzoni Hospital ASST Lecco , Lecco , Italy
| | - Lucia Del Vecchio
- a Department of Nephrology and Dialysis , A. Manzoni Hospital ASST Lecco , Lecco , Italy
| | - Giuseppe Pontoriero
- a Department of Nephrology and Dialysis , A. Manzoni Hospital ASST Lecco , Lecco , Italy
| | - Francesco Locatelli
- a Department of Nephrology and Dialysis , A. Manzoni Hospital ASST Lecco , Lecco , Italy
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Wen Y, Gan H, Li Z, Sun X, Xiong Y, Xia Y. Safety of Low-calcium Dialysate and its Effects on Coronary Artery Calcification in Patients Undergoing Maintenance Hemodialysis. Sci Rep 2018; 8:5941. [PMID: 29654308 PMCID: PMC5899126 DOI: 10.1038/s41598-018-24397-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 04/03/2018] [Indexed: 11/09/2022] Open
Abstract
To determine the safety of low-calcium-dialysate in patients undergoing maintenance hemodialysis (MHD) and its effects on coronary artery calcification (CAC) and analyze clinical risk factors for CAC. A total of 174 MHD patients were recruited and randomly divided into two groups: high-calcium dialysate (HCD, 1.5 mmol/L Ca2+) and low-calcium dialysate (LCD, 1.25 mmol/L Ca2+). Changes in CAC score (CACS) and cardiac function were evaluated using spiral computed tomography and echocardiography, respectively. Clinical and laboratory parameters were measured. Intra-dialysis adverse reactions were recorded and compared between the two groups. CACS was significantly lower in the LCD group than in the HCD group by the end of the study. Cardiac E/Amax was significantly higher in the LCD group than in the HCD group by the end of the study. There was no significant difference in the frequency of any intra-dialysis adverse reactions between the two groups during the study. LCD is helpful in maintaining cardiac diastolic function and postponing CAC progression. LCD does not increase intra-dialysis adverse reactions. Age may be the most important factor impacting CAC in MHD patients.
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Affiliation(s)
- Yang Wen
- The first affiliated hospital of Chongqing Medical University, Department of Nephrology, Chongqing, 400016, China
| | - Hua Gan
- The first affiliated hospital of Chongqing Medical University, Department of Nephrology, Chongqing, 400016, China
| | - Zhengrong Li
- The first affiliated hospital of Chongqing Medical University, Department of Nephrology, Chongqing, 400016, China
| | - Ximin Sun
- The first hospital affiliated to Army Medical University, Department of Hepatology, Chongqing, 400038, China
| | - Ying Xiong
- The first affiliated hospital of Chongqing Medical University, Department of Nephrology, Chongqing, 400016, China
| | - Yunfeng Xia
- The first affiliated hospital of Chongqing Medical University, Department of Nephrology, Chongqing, 400016, China.
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Vervloet MG, van Ballegooijen AJ. Prevention and treatment of hyperphosphatemia in chronic kidney disease. Kidney Int 2018; 93:1060-1072. [PMID: 29580635 DOI: 10.1016/j.kint.2017.11.036] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 11/21/2017] [Accepted: 11/27/2017] [Indexed: 12/20/2022]
Abstract
Hyperphosphatemia has consistently been shown to be associated with dismal outcome in a wide variety of populations, particularly in chronic kidney disease (CKD). Compelling evidence from basic and animal studies elucidated a range of mechanisms by which phosphate may exert its pathological effects and motivated interventions to treat hyperphosphatemia. These interventions consisted of dietary modifications and phosphate binders. However, the beneficial effects of these treatment methods on hard clinical outcomes have not been convincingly demonstrated in prospective clinical trials. In addition, exposure to high amounts of dietary phosphate may exert untoward actions even in the absence of overt hyperphosphatemia. Based on this concept, it has been proposed that the same interventions used in CKD patients with normal phosphate concentrations be used in the presence of hyperphosphatemia to prevent rise of phosphate concentration and as an early intervention for cardiovascular risk. This review describes conceptual models of phosphate toxicity, summarizes the evidence base for treatment and prevention of hyperphosphatemia, and identifies important knowledge gaps in the field.
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Affiliation(s)
- Marc G Vervloet
- Department of Nephrology, Amsterdam Cardiovascular Sciences, VU University Medical Center, Amsterdam, the Netherlands.
| | - Adriana J van Ballegooijen
- Department of Nephrology, Amsterdam Cardiovascular Sciences, VU University Medical Center, Amsterdam, the Netherlands; Department of Epidemiology and Biostatistics, Amsterdam Public Health Institute, VU University Medical Center, Amsterdam, the Netherlands
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Ketteler M. The Control of Hyperphosphatemia in Chronic Kidney Disease: Which Phosphate Binder? Int J Artif Organs 2018; 32:95-100. [DOI: 10.1177/039139880903200206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Hyperphosphatemia is currently regarded as a key mortality risk predictor in late CKD stages and especially in patients on dialysis. Fortunately, the armatorium to effectively treat hyperphosphatemia in end-stage renal disease has grown in recent years, and we gained an improved understanding of potential benefits and harms of specific compounds. Most interestingly, novel insights into the pathophysiology of calcium and phosphate handling, especially, the discovery of the phosphatonin FGF23, suggest a more complex assessment of phosphate balance especially in predialysis stages is warranted. This assessment should probably include measurements of fractional phosphate excretion and phosphatonin levels to objectively judge and effectively correct phosphate overload, however, clinical data on calcium and phosphate metabolism in CKD stages 3 – 4 are still scarce. This overview will both discuss aspects of pathophysiology of phosphate regulation and current and future clinical treatement approaches.
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Dzingarski D, Mladenovska K. Pharmacotherapy in chronic kidney disease hyperphosphatemia – effects on vascular calcification and bone health. MAKEDONSKO FARMACEVTSKI BILTEN 2017. [DOI: 10.33320/maced.pharm.bull.2017.63.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Hyperphosphatemia (HP) in patients with chronic kidney disease (CKD) leads to complications such as renal osteodistrophy, cardiovascular calcification and hemodynamic abnormalities, all of them having a serious impact on the survival rate and quality of life. Also, HP is a key pathogenic factor in the development of secondary hyperparathyroidism (SHPT) in CKD. Having in regard the significance of controlling serum phosphorus levels (Pi), in this paper, the needs and obstacles to successful pharmacological management of HP in CKD are presented, with an overview of major classes of phosphate binders (PBs) and other drugs affecting Pi level, such as active vitamin D sterols and calcimimetics (CMs). In addition, their effects on progression of cardiovascular calcification and bone health are elaborated. In this regard, a PubMed search was carried out to capture all abstracts and articles relevant to the topic of CKD, HP and mineral metabolism, bone disorders and vascular/valvular calcification (VC), published from January 2007 to August 2017. The search was limited to English language, with the search terms including drug name AND hyperphosphatemia or cardiovascular calcification or bone disorder. Comparative studies, clinical studies/trials and meta-analyses related to different classes/representatives of PBs, vitamin D analogues and CMs were reviewed and research data related to their efficacy and safety compared.
Keywords: chronic kidney disease, hyperphosphatemia, phosphate binders, active vitamin D sterols, calcimimetics, bone disorders, cardiovascular calcification
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Affiliation(s)
- Dimce Dzingarski
- Faculty of Pharmacy, University “Ss Cyril and Methodius”, Mother Theresa St. 47, 1000 Skopje, Republic of Macedonia
| | - Kristina Mladenovska
- Faculty of Pharmacy, University “Ss Cyril and Methodius”, Mother Theresa St. 47, 1000 Skopje, Republic of Macedonia
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Yang X, Bai Q, Li Y, Liu H, Guo H, Zhang X. Comparative Efficacy and Safety of Phosphate Binders in Hyperphosphatemia Patients With Chronic Kidney Disease. JPEN J Parenter Enteral Nutr 2017; 42:766-777. [PMID: 28777915 DOI: 10.1177/0148607117715440] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 05/23/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND In this study, we coordinated a network meta-analysis to establish the efficacy and safety of different agents used in the treatment of hyperphosphatemia patients with chronic kidney disease. METHODS PubMed, CNKI, and Embase were systematically searched to retrieve relevant studies. Outcomes were presented by mean differences, odds ratios, and corresponding 95% credible intervals for continuous outcomes and binary outcomes, respectively. Each therapy was ranked according to the value of surface under the cumulative ranking curve. Consistencies between direct and indirect comparisons were assessed with a node-splitting plot. RESULTS In terms of efficacy end points (including levels of serum phosphate, serum calcium, serum intact parathyroid hormone, and serum calcium × phosphorus product), all 7 kinds of agents outperformed or performed at least equally to placebo, with iron-based phosphate-binding agents being potentially the most effective. As for safety end points (including mortality, adverse events, and all-cause discontinuation), almost all agents were equivalent in term of mortality and all-cause discontinuation except in the comparison between iron-based phosphate-binding agents and placebo. Meanwhile, iron-based phosphate-binding agents colestilan and nicotinic acid performed poorly compared with placebo in terms of adverse events. Furthermore, iron-based phosphate-binding agents were potentially the safest agents followed sequentially by calcium-based phosphate-binding agents and placebo. CONCLUSION Iron-based phosphate-binding agents were the preferable agents when considering efficacy and safety simultaneously.
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Affiliation(s)
- Xiuqin Yang
- Department of Nephrology, Linyi People's Hospital, Linyi, Shandong, China
| | - Qingning Bai
- Department of Nephrology, Linyi People's Hospital, Linyi, Shandong, China
| | - Yanguo Li
- Department of Nephrology, Linyi People's Hospital, Linyi, Shandong, China
| | - Haijun Liu
- Linyi Medical College, Linyi, Shandong, China
| | - Haiying Guo
- Department of Nephrology, Linyi People's Hospital, Linyi, Shandong, China
| | - Xiaolei Zhang
- Department of Geriatrics, Linyi People's Hospital, Linyi, Shandong, China
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Liabeuf S, Ryckelynck JP, El Esper N, Ureña P, Combe C, Dussol B, Fouque D, Vanhille P, Frimat L, Thervet E, Mentaverri R, Prié D, Choukroun G. Randomized Clinical Trial of Sevelamer Carbonate on Serum Klotho and Fibroblast Growth Factor 23 in CKD. Clin J Am Soc Nephrol 2017; 12:1930-1940. [PMID: 29074818 PMCID: PMC5718266 DOI: 10.2215/cjn.03030317] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 08/15/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Epidemiologic studies suggest that higher serum phosphaturic hormone fibroblast growth factor 23 levels are associated with increase morbidity and mortality. The aim of the FGF23 Reduction Efficacy of a New Phosphate Binder in CKD Trial was to evaluate the effect of sevelamer carbonate on serum C-terminal fibroblast growth factor 23 levels in normophosphatemic patients with CKD stage 3b/4. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Patients with CKD, eGFR between 45 and 15 ml/min per 1.73 m2, fasting serum phosphate concentration >3.1 mg/dl, and serum C-terminal fibroblast growth factor 23 >80 relative units/ml were included in our double-blind, placebo-controlled, randomized multicenter study. All patients received 100,000 IU cholecalciferol at time of randomization. Participants received either placebo or sevelamer carbonate 4.8 g daily during a 12-week period. Biologic parameters, including serum C-terminal fibroblast growth factor 23, intact fibroblast growth factor 23, and α-klotho, were evaluated at baseline and 12 weeks after inclusion. RESULTS Of 96 screened patients, 78 (mean±SD age: 63±13 years old; 70% men; mean eGFR: 27±9 ml/min per 1.73 m2) met the inclusion criteria. At baseline, mean eGFR was 27±9 ml/min per 1.73 m2, mean serum phosphate level was 3.8±0.5 mg/dl, and median (interquartile range) serum C-terminal fibroblast growth factor 23 level was 157 (120-241) relative units/ml. After 12 weeks of treatment, urinary phosphate-to-creatinine ratio fell significantly in the sevelamer group. The sevelamer and placebo groups did not differ significantly in terms of median change in serum C-terminal fibroblast growth factor 23 levels: the median (interquartile range) change was 38 (-13-114) relative units/ml in the placebo group and 37 (-1-101) relative units/ml in the sevelamer group (P=0.77). There was no significant difference in serum intact fibroblast growth factor 23, α-klotho, or phosphate levels changes between the two groups. Serum total and LDL cholesterol levels fell significantly in the sevelamer group. CONCLUSIONS In our double-blind, placebo-controlled, randomized study performed in normophosphatemic patients with CKD, a 12-week course of sevelamer carbonate significantly reduced phosphaturia without changing serum phosphorus but did not significantly modify serum C-terminal fibroblast growth factor 23 and intact fibroblast growth factor 23 or α-klotho levels.
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Affiliation(s)
- Sophie Liabeuf
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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Vorland CJ, Martin BR, Weaver CM, Peacock M, Hill Gallant KM. Phosphorus Balance in Adolescent Girls and the Effect of Supplemental Dietary Calcium. JBMR Plus 2017; 2:103-108. [PMID: 29577111 DOI: 10.1002/jbm4.10026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
There are limited data on phosphorus balance and the effect of dietary calcium supplements on phosphorus balance in adolescents. The purpose of this study was to determine phosphorus balance and the effect of increasing dietary calcium intake with a supplement on net phosphorus absorption and balance in healthy adolescent girls. This study utilized stored urine, fecal, and diet samples from a previously conducted study that focused on calcium balance. Eleven healthy girls ages 11 to 14 years participated in a randomized crossover study, which consisted of two 3-week periods of a controlled diet with low (817 ± 19.5 mg/d) or high (1418 ± 11.1 mg/d) calcium, separated by a 1-week washout period. Phosphorus intake was controlled at the same level during both placebo and calcium supplementation (1435 ± 23.5 and 1453 ± 28.0 mg/d, respectively, p = 0.611). Mean phosphorus balance was positive by about 200 mg/d and was unaffected by the calcium supplement (p = 0.826). Urinary phosphorus excretion was lower with the calcium supplement (535 ± 42 versus 649 ± 41 mg/d, p = 0.013), but fecal phosphorus and net phosphorus absorption were not significantly different between placebo and calcium supplement (553 ± 60 versus 678 ± 63 versus mg/d, p = 0.143; 876 ± 62 versus 774 ± 64 mg/d, p = 0.231, respectively). Dietary phosphorus underestimates using a nutrient database compared with the content measured chemically from meal composites by ~40%. These results show that phosphorus balance is positive in girls during adolescent growth and that a calcium dietary supplement to near the current recommended level does not affect phosphorus balance when phosphorus intake is at 1400 mg/d, a typical US intake level.
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Affiliation(s)
- Colby J Vorland
- Department of Nutrition Science, Purdue University, West Lafayette, IN, USA
| | - Berdine R Martin
- Department of Nutrition Science, Purdue University, West Lafayette, IN, USA
| | - Connie M Weaver
- Department of Nutrition Science, Purdue University, West Lafayette, IN, USA
| | - Munro Peacock
- Department of Medicine, Division of Endocrinology, Indiana University School of Medicine, Indianapolis, IN, USA
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Căpuşă C, Ştefan G, Stancu S, Lipan M, Tsur LD, Mircescu G. Metabolic acidosis of chronic kidney disease and subclinical cardiovascular disease markers: Friend or foe? Medicine (Baltimore) 2017; 96:e8802. [PMID: 29381982 PMCID: PMC5708981 DOI: 10.1097/md.0000000000008802] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
The effect of chronic metabolic acidosis (MA) on cardiovascular disease (CVD) in the setting of chronic kidney disease (CKD) is largely unknown. Therefore, we aimed to study this relationship in nondialysis CKD patients.This cross-sectional, single-center study prospectively enrolled 95 clinically stable CKD patients (median age 61 (58, 65) years, 60% male, median eGFR 27 (22, 32) mL/min). Data on CKD etiology, CVD history, CVD traditional, and nontraditional risk factors were obtained. Also, markers of subclinical CVD were assessed: intima-media thickness (IMT), abdominal aortic calcifications (Kauppila score-AACs), cardio-ankle vascular index (CAVI), ankle-brachial index (ABI), ejection fraction, and interventricular septum thickness. Using the serum bicarbonate cutoff value of 22 mEq/L, comparisons between MA (<22 mEq/L; 43 patients) and non-MA (≥22 mEq/L; 52 patients) groups were performed.Vascular (40%), tubulointerstitial (24%), and glomerular (22%) nephropathies were the main causes of CKD. Twenty-three percent of patients had diabetes mellitus, but only 5% were considered to have diabetic nephropathy. Patients with chronic MA had lower eGFR (P < .01), higher iPTH (P = .01), higher serum phosphate (P < .01), and increased serum cholesterol (P = .04) and triglycerides (P = .01).Higher ABI (P = .04), lower IMT (P = .03), CAVI (P = .05), and AACs (P = .03) were found in patients with chronic MA.Separate binomial logistic regression models were performed using ABI (cutoff 0.9), CAVI (cutoff 9), IMT (cutoff 0.1 cm), and AACs (cutoff 1) as dependent variables. MA was used as independent variable and adjustments were made for iPTH, serum phosphate, eGFR, proteinuria, cholesterol, triglycerides, CVD score. The absence of MA was retained as an independent predictor only for the presence of AACs.In conclusion, the present study shows a potential advantageous effect of MA on vascular calcifications in predialysis CKD patients. Thus, a guideline relaxation of the serum bicarbonate target might prove to be beneficial in CKD patients at high risk of vascular calcifications. However, one should always consider the negative effects of MA. Therefore, additional research is warranted before any clear clinical recommendation.
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Affiliation(s)
- Cristina Căpuşă
- Nephrology Department, “Carol Davila” University of Medicine and Pharmacy
- “Dr Carol Davila” Teaching Hospital of Nephrology
| | - Gabriel Ştefan
- Nephrology Department, “Carol Davila” University of Medicine and Pharmacy
- “Dr Carol Davila” Teaching Hospital of Nephrology
| | - Simona Stancu
- Nephrology Department, “Carol Davila” University of Medicine and Pharmacy
- “Dr Carol Davila” Teaching Hospital of Nephrology
| | | | | | - Gabriel Mircescu
- Nephrology Department, “Carol Davila” University of Medicine and Pharmacy
- “Dr Carol Davila” Teaching Hospital of Nephrology
- Romanian Renal Registry, Bucharest, Romania
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Habbous S, Przech S, Acedillo R, Sarma S, Garg AX, Martin J. The efficacy and safety of sevelamer and lanthanum versus calcium-containing and iron-based binders in treating hyperphosphatemia in patients with chronic kidney disease: a systematic review and meta-analysis. Nephrol Dial Transplant 2017; 32:111-125. [PMID: 27651467 DOI: 10.1093/ndt/gfw312] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 07/13/2016] [Indexed: 12/17/2022] Open
Abstract
Background It remains unclear which phosphate binders should be preferred for hyperphosphatemia management in chronic kidney disease (CKD). Methods We performed a systematic review and meta-analysis of randomized trials comparing sevelamer or lanthanum with other phosphate binders in CKD. Results Fifty-one trials (8829 patients) were reviewed. Compared with calcium-based binders, all-cause mortality was nonsignificantly lower with sevelamer {risk ratio [RR] 0.62 [95% confidence interval (CI) 0.35-1.08]} and lanthanum [RR 0.73 (95% CI 0.18-3.00)], but risk of bias was concerning. Compared with calcium-based binders, sevelamer reduced the risk of hypercalcemia [RR 0.27 (95% CI 0.17-0.42)], as did lanthanum [RR 0.12 (95% CI 0.05-0.32)]. Sevelamer reduced hospitalizations [RR 0.50 (95% CI 0.31-0.81)], but not lanthanum [RR 0.80 (95% CI 0.34-1.93)]. The presence/absence of other clinically relevant outcomes was infrequently reported. Compared with calcium-based binders, sevelamer reduced serum calcium, low-density lipoprotein and coronary artery calcification, but increased intact parathyroid hormone. The clinical relevance of these changes is unknown since corresponding clinical outcomes were not reported. Lanthanum had less favorable impact on biochemical parameters. Sevelamer hydrochloride and sevelamer carbonate were similar in three studies. Sevelamer was similar to lanthanum (three studies) and iron-based binders (three studies). Conclusion Sevelamer was associated with a nonsignificant reduction in mortality and significantly lower hospitalization rates and hypercalcemia compared with calcium-based binders. However, differences in important outcomes, such as cardiac events, fractures, calciphylaxis, hyperchloremic acidosis and health-related quality of life remain understudied. Lanthanum and iron-based binders did not show superiority for any clinically relevant outcomes. Future studies that fail to measure clinically important outcomes (the reason why phosphate binders are prescribed in the first place) will be wasteful.
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Affiliation(s)
- Steven Habbous
- Department of Epidemiology & Biostatistics, Western University, London, ON, Canada
| | - Sebastian Przech
- Department of Epidemiology & Biostatistics, Western University, London, ON, Canada
| | - Rey Acedillo
- Department of Epidemiology & Biostatistics, Western University, London, ON, Canada.,London Health Sciences Centre, Division of Nephrology, Western University, London, ON, Canada
| | - Sisira Sarma
- Department of Epidemiology & Biostatistics, Western University, London, ON, Canada
| | - Amit X Garg
- Department of Epidemiology & Biostatistics, Western University, London, ON, Canada.,London Health Sciences Centre, Division of Nephrology, Western University, London, ON, Canada
| | - Janet Martin
- Department of Epidemiology & Biostatistics, Western University, London, ON, Canada.,Centre for Medical Evidence, Decision Integrity & Clinical Impact (MEDICI), Department of Anesthesia & Perioperative Medicine, Western University, London, ON, Canada
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Reid IR, Birstow SM, Bolland MJ. Calcium and Cardiovascular Disease. Endocrinol Metab (Seoul) 2017; 32:339-349. [PMID: 28956363 PMCID: PMC5620030 DOI: 10.3803/enm.2017.32.3.339] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 08/03/2017] [Accepted: 08/16/2017] [Indexed: 11/11/2022] Open
Abstract
Circulating calcium is a risk factor for vascular disease, a conclusion arising from prospective studies involving hundreds of thousands of participants and extending over periods of up to 30 years. These associations may be partially mediated by other cardiovascular risk factors such as circulating lipid levels, blood pressure, and body mass index, but there appears to be a residual independent effect of serum calcium. Polymorphisms of the calcium-sensing receptor associated with small elevations of serum calcium are also associated with cardiovascular disease, suggesting that calcium plays a causative role. Trials of calcium supplements in patients on dialysis and those with less severe renal failure demonstrate increased mortality and/or acceleration of vascular disease, and meta-analyses of trials in those without overt renal disease suggest a similar adverse effect. Interpretation of the latter trials is complicated by a significant interaction between baseline use of calcium supplements and the effect of randomisation to calcium in the largest trial. Restriction of analysis to those who are calcium-naive demonstrates a consistent adverse effect. Observational studies of dietary calcium do not demonstrate a consistent adverse effect on cardiovascular health, though very high or very low intakes may be deleterious. Thus, obtaining calcium from the diet rather than supplements is to be encouraged.
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Affiliation(s)
- Ian R Reid
- Department of Medicine, University of Auckland, Auckland, New Zealand
- Department of Endocrinology, Auckland District Health Board, Auckland, New Zealand.
| | - Sarah M Birstow
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Mark J Bolland
- Department of Medicine, University of Auckland, Auckland, New Zealand
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Bressendorff I, Hansen D, Schou M, Kragelund C, Brandi L. The effect of magnesium supplementation on vascular calcification in chronic kidney disease-a randomised clinical trial (MAGiCAL-CKD): essential study design and rationale. BMJ Open 2017; 7:e016795. [PMID: 28645983 PMCID: PMC5726116 DOI: 10.1136/bmjopen-2017-016795] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Chronic kidney disease (CKD) is associated with an increased risk of cardiovascular disease and mortality, which is thought to be caused by increased propensity towards vascular calcification (VC). Magnesium (Mg) inhibits phosphate-induced VC in vitro and in animal models and serum Mg is inversely associated with cardiovascular mortality in predialysis CKD and in end-stage renal disease. This paper will describe the design and rationale of a randomised double-blinded placebo-controlled multicentre clinical trial, which will investigate whether oral Mg supplementation can prevent the progression of coronary artery calcification (CAC) in subjects with predialysis CKD. METHODS AND ANALYSIS We will randomise 250 subjects with estimated glomerular filtration rate of 15 to 45 mL/min/1.73 m2 to 12 months treatment with either slow-release Mg hydroxide 30 mmol/day or matching placebo in a 1:1 ratio. The primary end point is change in CAC score as measured by CT at baseline and after 12 months treatment. Secondary end points include change in pulse wave velocity, bone mineral density, measures of mineral metabolism and clinical end points related to cardiovascular and renal events. ETHICS AND DISSEMINATION This trial has been approved by the local biomedical research ethics committees and data protection agencies and will be performed in accordance with the latest revision of the Helsinki Declaration. The trial will examine for the first time the effect of increasing the uptake of a putative VC inhibitor (ie, Mg) on progression of CAC in subjects with predialysis CKD. TRIAL REGISTRATION NUMBER NCT02542319, pre-results.
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Affiliation(s)
- Iain Bressendorff
- Department of Cardiology, Nephrology, and Endocrinology, Nordsjællands Hospital, Hillerød, Denmark
| | - Ditte Hansen
- Department of Nephrology, Herlev and Gentofte Hospital, Herlev, Denmark
| | - Morten Schou
- Department of Cardiology, Herlev and Gentofte Hospital, Herlev, Denmark
| | | | - Lisbet Brandi
- Department of Cardiology, Nephrology, and Endocrinology, Nordsjællands Hospital, Hillerød, Denmark
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KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD). Kidney Int Suppl (2011) 2017; 7:1-59. [PMID: 30675420 PMCID: PMC6340919 DOI: 10.1016/j.kisu.2017.04.001] [Citation(s) in RCA: 920] [Impact Index Per Article: 131.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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47
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Bravo-Soto GA, Madrid T. Sevelamer versus calcium-based phosphate binders for chronic kidney disease. Medwave 2017; 17:e6942. [DOI: 10.5867/medwave.2017.6942] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 03/01/2017] [Indexed: 11/27/2022] Open
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48
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Kim SJ, Lee YK, Oh J, Cho AJ, Noh JW. Effects of low calcium dialysate on the progression of coronary artery calcification in hemodialysis patients: An open-label 12-month randomized clinical trial. Int J Cardiol 2017; 243:431-436. [PMID: 28502735 DOI: 10.1016/j.ijcard.2017.05.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 04/27/2017] [Accepted: 05/03/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND The association between the dialysate calcium level and coronary artery calcification (CAC) has not yet been evaluated in hemodialysis patients. The objective of this study was to determine whether lowering the dialysate calcium levels would decrease the progression of coronary artery calcification (CAC) compared to using standard calcium dialysate. METHODS We conducted an open-label randomized trial with parallel groups. The patients were randomly assigned to either 12-month treatment with low calcium dialysate (LCD; 1.25mmol/L, n=36) or standard calcium dialysate (SCD; 1.5mmol/L, n=40). The primary outcome was the change in the CAC scores assessed by 64-slice multidetector computed tomography after 12months. RESULTS During the treatment period, CAC scores increased in both groups, especially significant in LCD group (402.5±776.8, 580.5±1011.9, P=0.004). When we defined progressors as patients at second and third tertiles of CAC changes, progressor group had a higher proportion of LCD-treated patients than SCD-treated patients (P=0.0229). In multivariate analysis, LCD treatment is a significant risk factor for increase in CAC scores (odds ratio=5.720, 95% CI: 1.219-26.843, P=0.027). CONCLUSIONS Use of LCD may accelerate the progression of CAC in patients with chronic hemodialysis over a 12-month period. TRIAL REGISTRATION Clinical Research Information Service [Internet]; Osong (Chungcheongbuk-do): Korea Centers for Disease Control and Prevention, Ministry of Health and Welfare (Republic of Korea), 2010: KCT0000942. Available from: https://cris.nih.go.kr/cris/search/search_result_st01_kren.jsp?seq=3572&sLeft=2&type=my.
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Affiliation(s)
- Soo Jin Kim
- Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, Republic of Korea; Hallym University Kidney Research Institute, Seoul, Republic of Korea
| | - Young-Ki Lee
- Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Republic of Korea; Hallym University Kidney Research Institute, Seoul, Republic of Korea.
| | - Jieun Oh
- Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, Republic of Korea; Hallym University Kidney Research Institute, Seoul, Republic of Korea
| | - AJin Cho
- Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Republic of Korea; Hallym University Kidney Research Institute, Seoul, Republic of Korea
| | - Jung Woo Noh
- Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Republic of Korea; Hallym University Kidney Research Institute, Seoul, Republic of Korea
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49
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Krishnasamy R, Pedagogos E. Should nephrologists consider vascular calcification screening? Nephrology (Carlton) 2017; 22 Suppl 2:31-33. [PMID: 28429546 DOI: 10.1111/nep.13019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Vascular calcification (VC) has been widely discussed over the last few decades and is associated with significant morbidity and mortality among patients with chronic kidney disease. Importantly, these patients have premature and rapidly progressive calcification when compared with the general population. VC is an active and complex process that is closely regulated by a growing list of inducers and inhibitors. VC can be detected using several non-invasive modalities including plain radiography, echocardiogram and computed tomography scans. However, the usefulness of these imaging measurements to capture treatment effects may be limited. Routine screening and monitoring for progression of VC remains highly debatable.
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Affiliation(s)
- Rathika Krishnasamy
- Department of Nephrology, Nambour General Hospital, Nambour, Queensland, Australia.,The University of Queensland, Brisbane, Queensland, Australia
| | - Eugenie Pedagogos
- Epworth Health Care, Melbourne, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia
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50
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Toussaint ND, Holt SG. Is serum phosphate a useful target in patients with chronic kidney disease and what is the role for dietary phosphate restriction? Nephrology (Carlton) 2017; 22 Suppl 2:36-41. [DOI: 10.1111/nep.13025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Nigel D Toussaint
- Department of Nephrology; The Royal Melbourne Hospital; Melbourne Parkville, Australia
- Department of Medicine; The University of Melbourne; Melbourne Australia
| | - Stephen G Holt
- Department of Nephrology; The Royal Melbourne Hospital; Melbourne Parkville, Australia
- Department of Medicine; The University of Melbourne; Melbourne Australia
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