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Lombardi G, Votrico V, Ferraro PM, Tassi S, Lissoni F, Ortalda V, Gambaro G. Intradialytic serum phosphate variations are associated with low PTH levels. J Nephrol 2024:10.1007/s40620-024-02062-y. [PMID: 39179746 DOI: 10.1007/s40620-024-02062-y] [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: 03/08/2024] [Accepted: 08/01/2024] [Indexed: 08/26/2024]
Abstract
BACKGROUND Numerous studies have explored the role of kidney replacement therapy (KRT) in phosphorus (P) control among prevalent hemodialysis (HD) patients. However, whether the reduction of P achieved during KRT affects parathyroid hormone (PTH) levels is still a matter of debate. METHODS We conducted a retrospective observational study on the prevalent HD population at the Division of Nephrology, University Hospital of Verona, from January to December 2022. We Included clinically stable adult patients undergoing HD for over 6 months, with multiple recorded visits during the follow-up. Demographic, clinical, laboratory, and medication data were collected. Time-varying variables were updated at each study visit. The primary outcome of interest was PTH levels. The absolute intra-HD change in P (intra-HD ∆P), defined as the difference between pre- and post-HD P levels, served as the main exposure. Multivariable adjusted linear mixed models were used to investigate the relationship between intra-HD ∆P and PTH levels. RESULTS A total of 211 patients contributed to 904 study visits. A significant and positive relationship was observed between intra-HD ∆P and pre-HD P (β = 0.76, 95% CI 0.75, 0.78, p < 0.001) and urea reduction ratio (β = 0.38, 95% CI 0.35, 0.41; p < 0.001). An increase in intra-HD ∆P was significantly and independently associated with low PTH levels (β = - 0.16, 95% CI - 0.30, -0.03; p = 0.020). CONCLUSIONS The extent of intra-HD P reduction significantly correlates with low PTH levels. Strategies focused on optimizing or enhancing depurative efficiency in KRT can exert a substantial impact on managing positive phosphorus balance and secondary hyperparathyroidism. The assessment of intra-HD P reduction may play a pivotal role in the management and follow-up of secondary hyperparathyroidism in HD patients.
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Affiliation(s)
- Gianmarco Lombardi
- Division of Nephrology, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy.
- Section of Nephrology, Department of Medicine, Università Degli Studi di Verona, Piazzale Aristide Stefani, 1, 37126, Verona, Italy.
| | - Valentina Votrico
- Section of Nephrology, Department of Medicine, Università Degli Studi di Verona, Piazzale Aristide Stefani, 1, 37126, Verona, Italy
| | - Pietro Manuel Ferraro
- Division of Nephrology, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
- Section of Nephrology, Department of Medicine, Università Degli Studi di Verona, Piazzale Aristide Stefani, 1, 37126, Verona, Italy
| | - Serena Tassi
- Section of Nephrology, Department of Medicine, Università Degli Studi di Verona, Piazzale Aristide Stefani, 1, 37126, Verona, Italy
| | - Francesca Lissoni
- Section of Nephrology, Department of Medicine, Università Degli Studi di Verona, Piazzale Aristide Stefani, 1, 37126, Verona, Italy
| | - Vittorio Ortalda
- Division of Nephrology, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Giovanni Gambaro
- Division of Nephrology, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
- Section of Nephrology, Department of Medicine, Università Degli Studi di Verona, Piazzale Aristide Stefani, 1, 37126, Verona, Italy
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Fedhila M, Belkacem Chebil R, Marmouch H, Terchalla S, Ayachi S, Oueslati Y, Oualha L, Douki N, Khochtali H. Brown Tumors of the Jaws: A Retrospective Study. Clin Med Insights Endocrinol Diabetes 2023; 16:11795514231210143. [PMID: 37942058 PMCID: PMC10629299 DOI: 10.1177/11795514231210143] [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: 03/06/2023] [Accepted: 10/11/2023] [Indexed: 11/10/2023] Open
Abstract
Objectives (1) Describe the clinical spectrum, imaging features, management, and outcome of brown tumors (BT) of the jaws. (2) Determine via a literature review the facts and controversies around the characteristics and management of this lesion. Materials and methods Our study was approved by the institutional committee of Sahloul University Hospital in accordance with the ethical standards of the Declaration of Helsinki. Sixteen patients with BT in the context of a primary, secondary, and tertiary hyperparathyroidism were treated and followed up during their recovery. Results This study reports 16 patients with a mean age of 48 years old. Brown tumor lesions were associated with primary hyperparathyroidism in 6 cases (38%), secondary hyperparathyroidism to chronic kidney failure in 5 cases (31%), and tertiary hyperparathyroidism in the context of a long lasting CRI in 5 cases. Their location was maxillary in 7 cases, mandibular in 5 cases, and bimaxillary in 4 cases. The treatment consisted of parathyroidectomy in 13 patients, maxillary resection in 3 cases, and vitamin D treatment in 2 cases. Favorable outcomes, characterized by tumor regression, were reported in 9 cases, whereas unfavorable evolution was observed among 7 patients. Conclusion Parathyroidectomy is the gold standard treatment for primary hyperparathyroidism. It resulted in a total regression in all our cases. Regarding secondary hyperparathyroidism, blood screening and chronic renal insufficiency follow-up are critically valuable to detect this condition at an early stage, hence increasing the success rate of brown tumor regression. Our secondary and tertiary hyperparathyroidism results were miscellaneous; although it is important to emphasize the importance of the chronic renal insufficiency management to ensure a success. Clinical relevance Brown tumors should be included in the differential diagnosis of giant cell lesions. Parathyroidectomy is usually sufficient to induce the total regression of the lesion in primary hyperparathyroidism cases. A more delicate approach is needed regarding secondary hyperparathyroidism. Meticulous control of chronic renal insufficiency is mandatory in addition to parathyroidectomy.
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Affiliation(s)
- Maya Fedhila
- Department of Oral Medicine and Oral Surgery, Sahloul Hospital (Sousse), Faculty of Dental Medicine of Monastir, University of Monastir, Monastir Tunisia
| | - Raouaa Belkacem Chebil
- Department of Oral Medicine and Oral Surgery, Sahloul Hospital (Sousse), Faculty of Dental Medicine of Monastir, University of Monastir, Monastir Tunisia
| | - Hela Marmouch
- Department of Endocrinology,Fattouma Bourguiba Hospital, Faculty of Medicine of Monastir, University of Monastir,Monastir, Tunisia
| | - Sabrine Terchalla
- Department of Oral Medicine and Oral Surgery, Sahloul Hospital (Sousse), Faculty of Dental Medicine of Monastir, University of Monastir, Monastir Tunisia
| | - Samia Ayachi
- Department of Maxillofacial Surgery, Sahloul Hospital (Sousse), Faculty of Medicine of Sousse, University of Sousse, Sousse, Tunisia
| | - Yassine Oueslati
- Department of Oral Medicine and Oral Surgery, Sahloul Hospital (Sousse), Faculty of Dental Medicine of Monastir, University of Monastir, Monastir Tunisia
| | - Lamia Oualha
- Department of Oral Medicine and Oral Surgery, Sahloul Hospital (Sousse), Faculty of Dental Medicine of Monastir, University of Monastir, Monastir Tunisia
| | - Nabiha Douki
- Department of Conservative Dentistry, Sahloul Hospital (Sousse), Faculty of Dental Medicine of Monastir, University of Monastir, Monastir, Tunisia
| | - Habib Khochtali
- Department of Maxillofacial Surgery, Sahloul Hospital (Sousse), Faculty of Medicine of Sousse, University of Sousse, Sousse, Tunisia
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Bone Disease in Chronic Kidney Disease and Kidney Transplant. Nutrients 2022; 15:nu15010167. [PMID: 36615824 PMCID: PMC9824497 DOI: 10.3390/nu15010167] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/19/2022] [Accepted: 12/19/2022] [Indexed: 12/31/2022] Open
Abstract
Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) comprises alterations in calcium, phosphorus, parathyroid hormone (PTH), Vitamin D, and fibroblast growth factor-23 (FGF-23) metabolism, abnormalities in bone turnover, mineralization, volume, linear growth or strength, and vascular calcification leading to an increase in bone fractures and vascular disease, which ultimately result in high morbidity and mortality. The bone component of CKD-MBD, referred to as renal osteodystrophy, starts early during the course of CKD as a result of the effects of progressive reduction in kidney function which modify the tight interaction between mineral, hormonal, and other biochemical mediators of cell function that ultimately lead to bone disease. In addition, other factors, such as osteoporosis not apparently dependent on the typical pathophysiologic abnormalities resulting from altered kidney function, may accompany the different varieties of renal osteodystrophy leading to an increment in the risk of bone fracture. After kidney transplantation, these bone alterations and others directly associated or not with changes in kidney function may persist, progress or transform into a different entity due to new pathogenetic mechanisms. With time, these alterations may improve or worsen depending to a large extent on the restoration of kidney function and correction of the metabolic abnormalities developed during the course of CKD. In this paper, we review the bone lesions that occur during both CKD progression and after kidney transplant and analyze the factors involved in their pathogenesis as a means to raise awareness of their complexity and interrelationship.
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Carrillo-López N, Panizo S, Arcidiacono MV, de la Fuente S, Martínez-Arias L, Ottaviano E, Ulloa C, Ruiz-Torres MP, Rodríguez I, Cannata-Andía JB, Naves-Díaz M, Dusso AS. Vitamin D Treatment Prevents Uremia-Induced Reductions in Aortic microRNA-145 Attenuating Osteogenic Differentiation despite Hyperphosphatemia. Nutrients 2022; 14:2589. [PMID: 35807767 PMCID: PMC9268464 DOI: 10.3390/nu14132589] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/20/2022] [Accepted: 06/20/2022] [Indexed: 02/01/2023] Open
Abstract
In chronic kidney disease, systemic inflammation and high serum phosphate (P) promote the de-differentiation of vascular smooth muscle cells (VSMC) to osteoblast-like cells, increasing the propensity for medial calcification and cardiovascular mortality. Vascular microRNA-145 (miR-145) content is essential to maintain VSMC contractile phenotype. Because vitamin D induces aortic miR-145, uremia and high serum P reduce it and miR-145 directly targets osteogenic osterix in osteoblasts, this study evaluated a potential causal link between vascular miR-145 reductions and osterix-driven osteogenic differentiation and its counter-regulation by vitamin D. Studies in aortic rings from normal rats and in the rat aortic VSMC line A7r5 exposed to calcifying conditions corroborated that miR-145 reductions were associated with decreases in contractile markers and increases in osteogenic differentiation and calcium (Ca) deposition. Furthermore, miR-145 silencing enhanced Ca deposition in A7r5 cells exposed to calcifying conditions, while miR-145 overexpression attenuated it, partly through increasing α-actin levels and reducing osterix-driven osteogenic differentiation. In mice, 14 weeks after the induction of renal mass reduction, both aortic miR-145 and α-actin mRNA decreased by 80% without significant elevations in osterix or Ca deposition. Vitamin D treatment from week 8 to 14 fully prevented the reductions in aortic miR-145 and attenuated by 50% the decreases in α-actin, despite uremia-induced hyperphosphatemia. In conclusion, vitamin D was able to prevent the reductions in aortic miR-145 and α-actin content induced by uremia, reducing the alterations in vascular contractility and osteogenic differentiation despite hyperphosphatemia.
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Grants
- PI11/00259, PI13/00497, PI14/01452, PI16/00637, PI17/02181, PI19/00532, PI20/00753 Instituto de Salud Carlos III
- RD16/0009/0017 Retic REDinREN
- RICORS2040 (Kidney Disease)
- GRUPIN14-028, IDI-2018-000152, IDI-2021-000080 Fondo Europeo de Desarrollo Regional (FEDER), Plan de Ciencia, Tecnología e Innovación 2013-2017 y 2018-2022 del Principado de Asturias
- Proyectos Luis Hernando (2019 and 2021) Fundación Renal
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Affiliation(s)
- Natalia Carrillo-López
- Bone and Mineral Research Unit, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (N.C.-L.); (S.P.); (L.M.-A.); (E.O.); (C.U.); (I.R.); (M.N.-D.)
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS), RICORS2040 (Kidney Disease), 28040 Madrid, Spain
| | - Sara Panizo
- Bone and Mineral Research Unit, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (N.C.-L.); (S.P.); (L.M.-A.); (E.O.); (C.U.); (I.R.); (M.N.-D.)
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS), RICORS2040 (Kidney Disease), 28040 Madrid, Spain
| | | | - Sandra de la Fuente
- Division of Experimental Nephrology, IRB Lleida, 25198 Lleida, Spain; (M.V.A.); (S.d.l.F.)
| | - Laura Martínez-Arias
- Bone and Mineral Research Unit, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (N.C.-L.); (S.P.); (L.M.-A.); (E.O.); (C.U.); (I.R.); (M.N.-D.)
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS), RICORS2040 (Kidney Disease), 28040 Madrid, Spain
| | - Emerenziana Ottaviano
- Bone and Mineral Research Unit, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (N.C.-L.); (S.P.); (L.M.-A.); (E.O.); (C.U.); (I.R.); (M.N.-D.)
| | - Catalina Ulloa
- Bone and Mineral Research Unit, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (N.C.-L.); (S.P.); (L.M.-A.); (E.O.); (C.U.); (I.R.); (M.N.-D.)
| | - María Piedad Ruiz-Torres
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS), RICORS2040 (Kidney Disease), 28040 Madrid, Spain
- Departamento de Biología de Sistemas, Universidad de Alcalá, 28801 Alcalá de Henares, Spain;
| | - Isabel Rodríguez
- Bone and Mineral Research Unit, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (N.C.-L.); (S.P.); (L.M.-A.); (E.O.); (C.U.); (I.R.); (M.N.-D.)
| | - Jorge B. Cannata-Andía
- Bone and Mineral Research Unit, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (N.C.-L.); (S.P.); (L.M.-A.); (E.O.); (C.U.); (I.R.); (M.N.-D.)
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS), RICORS2040 (Kidney Disease), 28040 Madrid, Spain
- Departamento de Medicina, Universidad de Oviedo, 33006 Oviedo, Spain
| | - Manuel Naves-Díaz
- Bone and Mineral Research Unit, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (N.C.-L.); (S.P.); (L.M.-A.); (E.O.); (C.U.); (I.R.); (M.N.-D.)
- Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS), RICORS2040 (Kidney Disease), 28040 Madrid, Spain
| | - Adriana S. Dusso
- Bone and Mineral Research Unit, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (N.C.-L.); (S.P.); (L.M.-A.); (E.O.); (C.U.); (I.R.); (M.N.-D.)
- Division of Experimental Nephrology, IRB Lleida, 25198 Lleida, Spain; (M.V.A.); (S.d.l.F.)
- Division of Endocrinology, Metabolism and Lipid Research, Washington University School of Medicine, St. Louis, MO 63110, USA
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Vitamin D and Phosphate Interactions in Health and Disease. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1362:37-46. [DOI: 10.1007/978-3-030-91623-7_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Dusso AS, Bauerle KT, Bernal-Mizrachi C. Non-classical Vitamin D Actions for Renal Protection. Front Med (Lausanne) 2021; 8:790513. [PMID: 34950686 PMCID: PMC8688743 DOI: 10.3389/fmed.2021.790513] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/15/2021] [Indexed: 11/17/2022] Open
Abstract
Chronic Kidney Disease (CKD), a disorder that affects 11% of the world's population, is characterized by an acceleration in skeletal, immune, renal, and cardiovascular aging that increases the risk of cardiovascular mortality by 10- to 20-fold, compared to that in individuals with normal renal function. For more than two decades, the progressive impairment in renal capacity to maintain normal circulating levels of the hormonal form of vitamin D (1,25-dihydroxyvitamin D or calcitriol) was considered the main contributor to the reduced survival of CKD patients. Accordingly, calcitriol administration was the treatment of choice to attenuate the progression of secondary hyperparathyroidism (SHPT) and its adverse impact on bone health and vascular calcification. The development of calcitriol analogs, designed to mitigate the resistance to calcitriol suppression of PTH associated with CKD progression, demonstrated survival benefits unrelated to the control of SHPT or skeletal health. The exhaustive search for the pathophysiology behind survival benefits associated with active vitamin D analogs has identified novel anti-inflammatory, anti-hypertensive, anti-aging actions of the vitamin D endocrine system. A major paradigm shift regarding the use of calcitriol or active vitamin D analogs to improve survival in CKD patients emerged upon demonstration of a high prevalence of vitamin D (not calcitriol) deficiency at all stages of CKD and, more significantly, that maintaining serum levels of the calcitriol precursor, 25(OH)vitamin D, above 23 ng/ml delayed CKD progression. The cause of vitamin D deficiency in CKD, however, is unclear since vitamin D bioactivation to 25(OH)D occurs mostly at the liver. Importantly, neither calcitriol nor its analogs can correct vitamin D deficiency. The goals of this chapter are to present our current understanding of the pathogenesis of vitamin D deficiency in CKD and of the causal link between defective vitamin D bioactivation to calcitriol and the onset of molecular pathways that promote CKD progression independently of the degree of SHPT. An understanding of these mechanisms will highlight the need for identification of novel sensitive biomarkers to assess the efficacy of interventions with vitamin D and/or calcitriol(analogs) to ameliorate CKD progression in a PTH-independent manner.
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Affiliation(s)
- Adriana S. Dusso
- Division of Endocrinology, Metabolism and Lipid Research, Department of Medicine, Washington University School of Medicine, St. Louis, MO, United States
| | - Kevin T. Bauerle
- Division of Endocrinology, Metabolism and Lipid Research, Department of Medicine, Washington University School of Medicine, St. Louis, MO, United States
- Department of Medicine, VA Medical Center, St. Louis, MO, United States
| | - Carlos Bernal-Mizrachi
- Division of Endocrinology, Metabolism and Lipid Research, Department of Medicine, Washington University School of Medicine, St. Louis, MO, United States
- Department of Medicine, VA Medical Center, St. Louis, MO, United States
- Department of Cell Biology and Physiology, Washington University School of Medicine, St. Louis, MO, United States
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Kamio K, Morita J, Nakanishi Y, Sasaki M, Wakamatsu M. Corneal lesions related to an anesthetic mixture of medetomidine, midazolam, and butorphanol treatment in rats. J Toxicol Sci 2021; 46:561-568. [PMID: 34853242 DOI: 10.2131/jts.46.561] [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: 11/02/2022]
Abstract
An anesthetic mixture of medetomidine, midazolam and butorphanol (MMB) has been recently used in laboratory animals. We observed corneal opacity in nephrectomized rats that had undergone two operations under MMB anesthesia at 4 and 5 weeks of age. To evaluate the features of this corneal opacity, ophthalmic examinations were conducted in 83 nephrectomized rats, and 8 representative animals with corneal opacity were evaluated histopathologically 4 weeks after operation. The ophthalmic examinations revealed that 66/83 animals had corneal opacity, which was characterized histopathologically by mineralization with or without inflammation in the corneal stroma. In addition, to examine the possible causes of this corneal opacity, we investigated whether similar corneal changes were induced by the MMB anesthetic treatment in normal rats. The MMB anesthetic was administered twice to 4- and 5-week-old normal SD rats (5 animals/age) in the same manner as for the nephrectomized rats. Ophthalmic examinations were conducted in all the animals once a week, and the animals were necropsied 4 weeks after the first administration. In normal rats, similar corneal opacity was observed after the first administration, and increases in the severity and size of the corneal opacity were noted after the second administration. In conclusion, this study revealed the features of corneal opacity in rats undergoing nephrectomy under MMB anesthesia and the occurrence of similar corneal opacity in normal rats treated with MMB anesthetic. To the best of our knowledge, this is the first report of corneal opacity related to MMB anesthetic treatment in rats.
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Affiliation(s)
- Kyohei Kamio
- Drug Safety and Pharmacokinetics Laboratories, Research Headquarters, Taisho Pharmaceutical Co., Ltd
| | - Junya Morita
- Drug Safety and Pharmacokinetics Laboratories, Research Headquarters, Taisho Pharmaceutical Co., Ltd
| | - Yutaka Nakanishi
- Drug Safety and Pharmacokinetics Laboratories, Research Headquarters, Taisho Pharmaceutical Co., Ltd
| | - Minoru Sasaki
- Senior Specialist Office, Pharmaceutical Product, Taisho Pharmaceutical Co., Ltd
| | - Masaki Wakamatsu
- Drug Safety and Pharmacokinetics Laboratories, Research Headquarters, Taisho Pharmaceutical Co., Ltd
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Pichone A, Campos G, Leite M, Gomes CP. High ankle-brachial index predicts cardiovascular events and mortality in hemodialysis patients with severe secondary hyperparathyroidism. J Bras Nefrol 2021; 43:478-485. [PMID: 33979425 PMCID: PMC8940110 DOI: 10.1590/2175-8239-jbn-2020-0218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 03/23/2021] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Vascular calcification related to severe secondary hyperparathyroidism (SHPT) is an important cause of cardiovascular and bone complications, leading to high morbidity and mortality in patients with chronic kidney disease (CKD) undergoing hemodialysis (HD). The present study aimed to analyze whether ankle-brachial index (ABI), a non-invasive diagnostic tool, is able to predict cardiovascular outcomes in this population. METHODS We selected 88 adult patients on HD for at least 6 months, with serum iPTH>1,000pg/mL. We collected clinical data, biochemical and hormonal parameters, and ABI (sonar-Doppler). Calcification was assessed by lateral radiography of the abdomen and by simple vascular calcification score (SVCS). This cohort was monitored prospectively between 2012 and 2019 for cardiovascular outcomes (death, myocardial infarction (MI), stroke, and calciphylaxis) to estimate the accuracy of ABI in this setting. RESULTS The baseline values were: iPTH: 1770±689pg/mL, P: 5.8±1.2 mg/dL, corrected Ca: 9.7±0.8mg/dL, 25(OH)vit D: 25.1±10.9ng/mL. Sixty-five percent of patients had ABI>1.3 (ranging from 0.6 to 3.2); 66% had SVCS≥3, and 45% aortic calcification (Kauppila≥8). The prospective evaluation (51.6±24.0 months), provided the following cardiovascular outcomes: 11% of deaths, 17% of nonfatal MI, one stroke, and 3% of calciphylaxis. After adjustments, patients with ABI≥1.6 had 8.9-fold higher risk of cardiovascular events (p=0.035), and ABI≥1.8 had 12.2-fold higher risk of cardiovascular mortality (p=0.019). CONCLUSION The presence of vascular calcifications and arterial stiffness was highly prevalent in our population. We suggest that ABI, a simple and cost-effective diagnostic tool, could be used at an outpatient basis to predict cardiovascular events in patients with severe SHPT undergoing HD.
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Affiliation(s)
- Alinie Pichone
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Divisão de Nefrologia, Rio de Janeiro, RJ, Brasil
| | - Gabriela Campos
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Divisão de Nefrologia, Rio de Janeiro, RJ, Brasil
| | - Maurilo Leite
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Divisão de Nefrologia, Rio de Janeiro, RJ, Brasil
| | - Carlos Perez Gomes
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Divisão de Nefrologia, Rio de Janeiro, RJ, Brasil
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Kojic acid derivatives as double face ligands for metal and phosphate ions. J Inorg Biochem 2021; 222:111520. [PMID: 34171770 DOI: 10.1016/j.jinorgbio.2021.111520] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/31/2021] [Accepted: 06/15/2021] [Indexed: 12/25/2022]
Abstract
A family of combined Kojic acid and polyamine derivatives has been synthesized as phosphate anion and metal ion ligands. The stoichiometry, stability and structure of the ion/ligand adducts were determined by 1H NMR spectroscopy, potentiometry, EXAFS and DFT calculations. The presented dual ligands bind effectively both phosphate anions and metal ions and could be used as effective ion receptors in challenging water conditions in the broad pH range. A careful analysis of the heatmaps of the stability constants allows to choose the most appropriate ligand for the ion for qualitative and/or quantitative analysis in water, without analyte pre-treatment. Extremely high-water solubility (>0.6 M) and ion(s)/ligand stability of the adducts in the pH 3-11 are the greatest advantages of the presented here molecules over other known ion sensors. The presented here molecules represent an innovative class of dual metal/anion ligands, with perspective of medical and environmental use.
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Gaweda AE, McBride DE, Lederer ED, Brier ME. Development of a quantitative systems pharmacology model of chronic kidney disease: metabolic bone disorder. Am J Physiol Renal Physiol 2021; 320:F203-F211. [PMID: 33308018 PMCID: PMC11163996 DOI: 10.1152/ajprenal.00159.2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 11/23/2020] [Accepted: 12/10/2020] [Indexed: 01/01/2023] Open
Abstract
Chronic kidney disease mineral bone disorder (CKD-MBD) is a virtually universal complication of kidney diseases, starting early in the course of disease and resulting in devastating clinical consequences ranging from bone fragility to accelerated atherosclerosis and early cardiovascular death. Guidelines for therapeutic goals for CKD-MBD have been published, and achievement of these guidelines is associated with improved survival. However, the incomplete understanding of CKD-MBD and the individual variability in the manifestations of CKD-MBD have made it difficult to achieve these guidelines. We hypothesized that the progression of MBD through all stages of CKD, including end-stage kidney disease, could be represented by a quantitative systems pharmacology/systems biology (QSP) model. To address this hypothesis, we constructed a QSP model of CKD-MBD, building on an open-source model of calcium and phosphorus metabolism. Specifically, we estimated and validated the model using data from 5,496 patients with CKD enrolled in the Chronic Renal Insufficiency Cohort study. Our model accurately predicted changes in markers of mineral metabolism related to progressing CKD. We demonstrated that the incorporation of fibroblast growth factor 23 and the soft tissue compartment is essential for accurate modeling of the changes in calcium, phosphorus, intact parathyroid hormone, and calcitriol in CKD-MBD. We conclude that our systems biology model accurately represents CKD-MBD disease progression and can be used as a test bench for improving therapeutic interventions.
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Affiliation(s)
- Adam E Gaweda
- Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Devin E McBride
- Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Eleanor D Lederer
- Medical Services, Veterans Affairs North Texas Health Sciences Center, Dallas, Texas
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michael E Brier
- Department of Medicine, University of Louisville, Louisville, Kentucky
- Research Services, Robley Rex Veterans Affairs Medical Center, Louisville, Kentucky
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Chen J, Feng J, Zhou Q, Zheng W, Meng X, Wang Y, Wang J. Intraoperative 99mTc-MIBI-Guided Parathyroidectomy Improves Curative Effect of Parathyroidectomy, Bone Metabolism, and Bone Mineral Density. Am Surg 2020; 87:463-472. [PMID: 33047971 DOI: 10.1177/0003134820951467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study aimed to compare the postoperative effects of total parathyroidectomy plus forearm transplantation and radioguided parathyroidectomy on bone metabolism and bone mineral density (BMD). From June 2013 to October 2017, 67 patients with renal secondary hyperparathyroidism (SHPT) received surgical treatment. The control group included 30 cases of classical total parathyroidectomy plus forearm transplantation for SHPT. In the experimental group, 37 patients underwent 99mTc-MIBI-guided parathyroidectomy. Demographics, parathyroid hormone (PTH) level, blood calcium level, and pathological results were compared between the 2 groups. The curative effect of parathyroidectomy and its effect on BMD were also compared. The BMDs in the L1-L4 segments and femoral neck in both groups were significantly improved after operation (all P < .05). The T scores of the L1-L4 segments and femoral neck in both groups were significantly improved after operation (all P < .05). The improvement in the T score of the L4 in the experimental group was significantly higher than that in the control group (P < .05). No significant differences in the improvement in the L1-L3 segments and femoral neck were found between the 2 groups. Both traditional total parathyroidectomy plus forearm transplantation and 99mTc-MIBI-guided parathyroidectomy can improve PTH level, blood calcium level, phosphorus level, bone metabolism, and BMD to varying degrees in patients with SHPT. Compared with the traditional surgery, 99mTc-MIBI-guided parathyroidectomy can improve blood calcium and phosphorus metabolisms, reduce PTH level, and improve the T scores of L4 to a greater extent.
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Affiliation(s)
- Jun Chen
- 56694 Department of Head and Neck Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jialin Feng
- 56694 Department of Head and Neck Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qinyi Zhou
- 56694 Department of Head and Neck Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wenjie Zheng
- 56694 Department of Head and Neck Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiangchao Meng
- 56694 Department of Bone and Joint Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - You Wang
- 56694 Department of Bone and Joint Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jiadong Wang
- 56694 Department of Head and Neck Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Warady BA, Ng E, Bloss L, Mo M, Schaefer F, Bacchetta J. Cinacalcet studies in pediatric subjects with secondary hyperparathyroidism receiving dialysis. Pediatr Nephrol 2020; 35:1679-1697. [PMID: 32367309 PMCID: PMC7385021 DOI: 10.1007/s00467-020-04516-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 02/18/2020] [Accepted: 02/21/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Secondary hyperparathyroidism (sHPT), a complication of chronic kidney disease (CKD) characterized by persistently elevated parathyroid hormone (PTH), alterations in calcium-phosphorus homeostasis, and vitamin D metabolism, affects 50% of children receiving dialysis. A significant proportion of these children develop CKD-mineral and bone disorder (CKD-MBD), associated with an increased risk of fractures and vascular calcification. The standard of care for sHPT in children includes vitamin D sterols, calcium supplementation, and phosphate binders. Several agents are approved for sHPT treatment in adults undergoing dialysis, including vitamin D analogs and calcimimetics, with limited information on their safety and efficacy in children. The calcimimetic cinacalcet is approved for use in adults with sHPT on dialysis, but is not approved for pediatric use outside Europe. METHODS This review provides dosing, safety, and efficacy information from Amgen-sponsored cinacalcet pediatric trials and data from non-Amgen sponsored clinical studies. RESULTS The Amgen cinacalcet pediatric clinical development program consisted of two Phase 3 randomized studies, one Phase 3 single arm extension study, one open-label Phase 2 study, and two open-label Phase 1 studies. Effects of cinacalcet on PTH varied across studies. Overall, 7.4 to 57.1% of subjects who received cinacalcet in an Amgen clinical trial attained PTH levels within recommended target ranges and 22.2 to 70.6% observed a ≥ 30% reduction in PTH. In addition, significant reductions in PTH were demonstrated in all non-Amgen-supported studies. CONCLUSIONS To help inform the pediatric nephrology community, this manuscript contains the most comprehensive review of cinacalcet usage in pediatric CKD patients to date.
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Affiliation(s)
- Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, MO, USA.
| | - Eric Ng
- Amgen Inc., Thousand Oaks, CA, USA
| | | | - May Mo
- Amgen Inc., Thousand Oaks, CA, USA
| | | | - Justine Bacchetta
- Department of Pediatric Nephrology, Rheumatology and Dermatology, Femme Mère Enfant Hospital, Bron, France
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Bageac D, DeBevits JJ, Munbodh R, Kaplan J, Wu R, DiCamillo PA, Hu C, Wang Y, Karimeddini D, Naismith RT, Dhib-Jalbut S, Wolansky L. MRI demonstration of gadolinium deposition in bone after monthly triple-dose gadopentetate dimeglumine and correlation with frequency of hypophosphatemia. Clin Imaging 2020; 70:136-141. [PMID: 33161342 DOI: 10.1016/j.clinimag.2020.07.022] [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: 05/15/2020] [Revised: 07/03/2020] [Accepted: 07/27/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES We retrospectively analyzed data of the BECOME trial to investigate whether serial administration of triple-dose (3-dose) gadopentetate dimeglumine would result in the development of T1 signal-to-noise (S/N) changes in the cranial diploic space and whether S/N changes correlated with on-study hypophosphatemia. METHODS Signal intensity analysis was performed on the first year's data of the BECOME trial using 3-dose Gd (14 months, maximum number of doses, 39, mean: 36). Routine blood and urine tests were obtained each month for safety monitoring. Linear mixed regression modeling with random intercept was used to analyze monthly signal-to-noise ratio (S/N = Bone/Air) using an ROI of the diploic space created from T2W images and overlaid on T1FS (T1 fat-saturated) images. Incidence of phosphate abnormalities was analyzed using the general estimation equation; correlation of phosphate and S/N change was achieved with type 3 test of fixed effects. RESULTS Cranial diploic space T1FS S/N increased over 14 months: S/N = 0.039 mean monthly increase (S.E. 0.008; p < 0.0001). Subjects with consistently normal phosphate levels (n = 32) experienced more of a S/N increase than patients with at least one episode of hypophosphatemia (n = 35) (0.057 vs. 0.023, respectively, p = 0.037). Those with moderate hypophosphatemia demonstrated no significant S/N increase. CONCLUSION Monthly administration of 3-dose gadopentetate dimeglumine is associated with development of increased S/N on T1FS imaging in the cranial diploic space, suggesting Gd retention in bone. Our data suggests MRI could be used as a noninvasive method of tracking Gd retention in bone, which was more pronounced in patients with normal phosphate levels.
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Affiliation(s)
- Devin Bageac
- University of Connecticut School of Medicine, 263 Farmington Ave, Farmington, CT 06030, United States of America
| | - John J DeBevits
- University of Connecticut School of Medicine, 263 Farmington Ave, Farmington, CT 06030, United States of America
| | - Reshma Munbodh
- Brown University, Alpert Medical School, 222 Richmond St, Providence, RI 02903, United States of America
| | - Joshua Kaplan
- Rutgers New Jersey Medical School, 185 S Orange Ave, Newark, NJ 07103, United States of America
| | - Rong Wu
- University of Connecticut School of Medicine, 263 Farmington Ave, Farmington, CT 06030, United States of America
| | - Paul A DiCamillo
- University of Iowa School of Medicine, 375 Newton Rd, Iowa City, IA 52242, United States of America
| | - Chaoran Hu
- University of Connecticut School of Medicine, 263 Farmington Ave, Farmington, CT 06030, United States of America
| | - Yanlin Wang
- University of Connecticut School of Medicine, 263 Farmington Ave, Farmington, CT 06030, United States of America
| | - David Karimeddini
- University of Connecticut School of Medicine, 263 Farmington Ave, Farmington, CT 06030, United States of America
| | - Robert T Naismith
- Washington U. of St. Louis, Medical School, 660 S Euclid Ave, St. Louis, MO 63110, United States of America
| | - Suhayl Dhib-Jalbut
- Rutgers New Jersey Medical School, 185 S Orange Ave, Newark, NJ 07103, United States of America
| | - Leo Wolansky
- University of Connecticut School of Medicine, 263 Farmington Ave, Farmington, CT 06030, United States of America.
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Tsuboi Y, Ohtomo S, Ichida Y, Hagita H, Ozawa K, Iida M, Nagao S, Ikegami H, Takahashi T, Horiba N. EOS789, a novel pan-phosphate transporter inhibitor, is effective for the treatment of chronic kidney disease-mineral bone disorder. Kidney Int 2020; 98:343-354. [PMID: 32624180 DOI: 10.1016/j.kint.2020.02.040] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 02/18/2020] [Accepted: 02/28/2020] [Indexed: 12/13/2022]
Abstract
Chronic kidney disease is characterized as impaired renal function along with the imbalance and dysregulation of mineral metabolism; recognized as chronic kidney disease-mineral and bone disorder. Hyperphosphatemia, characterized by altered phosphate homeostasis along with elevated fibroblast growth factor-23 and intact parathyroid hormone, is such an alteration of mineral metabolism. We discovered a novel inhibitor, EOS789, that interacts with several sodium-dependent phosphate transporters (NaPi-IIb, PiT-1, and PiT-2) known to contribute to intestinal phosphate absorption. This inhibitor dose-dependently increased the fecal phosphorus excretion rate and inversely decreased the urinary phosphorus excretion rate in normal rats, suggesting inhibition of intestinal phosphorus absorption. In rats with adenine-induced hyperphosphatemia, EOS789 markedly decreased the serum phosphate, fibroblast growth factor-23, and intact parathyroid hormone below values found in normal control rats. Notably, this pan-phosphate transporter inhibitor exhibited a more potent effect on serum phosphate than a NaPi-IIb-selective inhibitor in rats with hyperphosphatemia indicating that PiT-1 and PiT-2 play important roles in intestinal phosphate absorption. Moreover, in a long-term study, EOS789 sustained the suppression of serum phosphorus in parallel with fibroblast growth factor-23 and intact parathyroid hormone and ameliorated ectopic calcification of the thoracic aorta. Additionally, EOS789 treatment also ameliorated kidney deterioration in rats with progressive kidney injury, probably due to the strict phosphate control. Thus, EOS789 has potent efficacy against hyperphosphatemia and its complications and could provide a significant benefit to patients who are ineffectively treated with phosphate binders.
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Affiliation(s)
- Yoshinori Tsuboi
- Research Division, Chugai Pharmaceutical Co., Ltd., Gotemba, Shizuoka, Japan
| | - Shuichi Ohtomo
- Research Division, Chugai Pharmaceutical Co., Ltd., Gotemba, Shizuoka, Japan.
| | - Yasuhiro Ichida
- Research Division, Chugai Pharmaceutical Co., Ltd., Gotemba, Shizuoka, Japan
| | - Hitoshi Hagita
- Chugai Research Institute for Medical Science, Inc., Gotemba, Shizuoka, Japan
| | - Kazuharu Ozawa
- Research Division, Chugai Pharmaceutical Co., Ltd., Gotemba, Shizuoka, Japan
| | - Manami Iida
- Research Division, Chugai Pharmaceutical Co., Ltd., Gotemba, Shizuoka, Japan
| | - Shunsuke Nagao
- Translational Research Division, Chugai Pharmaceutical Co., Ltd., Kamakura, Kanagawa, Japan
| | - Hisashi Ikegami
- Translational Research Division, Chugai Pharmaceutical Co., Ltd., Kamakura, Kanagawa, Japan
| | - Tadakatsu Takahashi
- Research Division, Chugai Pharmaceutical Co., Ltd., Gotemba, Shizuoka, Japan
| | - Naoshi Horiba
- Research Division, Chugai Pharmaceutical Co., Ltd., Gotemba, Shizuoka, Japan
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Barley-ß-glucans reduce systemic inflammation, renal injury and aortic calcification through ADAM17 and neutral-sphingomyelinase2 inhibition. Sci Rep 2019; 9:17810. [PMID: 31780737 PMCID: PMC6882851 DOI: 10.1038/s41598-019-54306-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 11/06/2019] [Indexed: 11/18/2022] Open
Abstract
In chronic kidney disease (CKD), hyperphosphatemia-induced inflammation aggravates vascular calcification (VC) by increasing vascular smooth muscle cell (VSMC) osteogenic differentiation, ADAM17-induced renal and vascular injury, and TNFα-induction of neutral-sphingomyelinase2 (nSMase2) to release pro-calcifying exosomes. This study examined anti-inflammatory β-glucans efficacy at attenuating systemic inflammation in health, and renal and vascular injury favoring VC in hyperphosphatemic CKD. In healthy adults, dietary barley β-glucans (Bβglucans) reduced leukocyte superoxide production, inflammatory ADAM17, TNFα, nSMase2, and pro-aging/pro-inflammatory STING (Stimulator of interferon genes) gene expression without decreasing circulating inflammatory cytokines, except for γ-interferon. In hyperphosphatemic rat CKD, dietary Bβglucans reduced renal and aortic ADAM17-driven inflammation attenuating CKD-progression (higher GFR and lower serum creatinine, proteinuria, kidney inflammatory infiltration and nSMase2), and TNFα-driven increases in aortic nSMase2 and calcium deposition without improving mineral homeostasis. In VSMC, Bβglucans prevented LPS- or uremic serum-induced rapid increases in ADAM17, TNFα and nSMase2, and reduced the 13-fold higher calcium deposition induced by prolonged calcifying conditions by inhibiting osteogenic differentiation and increases in nSMase2 through Dectin1-independent actions involving Bβglucans internalization. Thus, dietary Bβglucans inhibit leukocyte superoxide production and leukocyte, renal and aortic ADAM17- and nSMase2 gene expression attenuating systemic inflammation in health, and renal injury and aortic calcification despite hyperphosphatemia in CKD.
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Abstract
Purpose
This paper is a systemic review on enset plant’s role in Ethiopian people’s life as the source of food. This paper aims to summarize the traditional processing and preparation methods of enset-based foods and their nutritional composition.
Design/methodology/approach
Available scientific articles were collected and reviewed for enset plant evaluation, description, enset plant’s role in Ethiopian people’s food security, post harvesting and traditional processing of enset plants, microbiology of the fermented enset foods, different foods reported from enset, nutritional profile of the three food from enset base (kocho, bulla and amicho) and other non-food applications of enset plant.
Findings
Enset plant has a predominant role in people living in the southern part of Ethiopia. This plant is drought-tolerant and provides many non-food applications. Harvesting of the enset plant, preparing for fermentation and food preparations follow the traditional route by using the indigenous knowledge and practices. Limited studies have been reported on the microbiology of the enset fermentation, but various types of microbes have been reported. In case of nutritional composition, foods from enset are reported to contain high carbohydrate and minerals content, such as calcium, potassium and zinc, but limited protein content; they are also the best source of the essential amino acids such as lysine and leucine. Limited data are available on vitamins, anti-oxidant and fatty acids profiles of enset-based foods. The existing data indicate variations, and the reasons for variability are discussed in this paper.
Originality/value
Scientific reviews on enset food nutrition profile and related issues are scarce; this paper will compile information about enset plant-based foods for researchers for their future research.
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Calcium-Phosphate Metabolism Disorders in Patients with Renal Failure Clinical Significance, Diagnosis and Treatment. ACTA MEDICA BULGARICA 2019. [DOI: 10.2478/amb-2019-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Chronic kidney diseases (CKD) are commonly associated with calcium and phosphorus metabolism disorders. The general term of “renal osteodystrophy” (ROD) encompasses a complex spectrum of abnormalities in bone and mineral metabolism in CKD. This is one of the most serious and debilitating complications of CKD. It is related to disproportionately high direct and indirect costs of healthcare, thus posing a major burden on society. The development of ROD begins too early in the course of CKD. Some mechanisms involved in the pathogenesis of ROD are reduced calciferol production, calcium deficiency and hyperphosphatemia. Clinically, ROD occurs with varied manifestations – osteomalacia, osteoporosis, adynamic bone disease. The diagnosis and the treatment are a challenge for the physician and effort should be made to prolong the duration and quality of life of the affected patients.
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Exploring the Link between Serum Phosphate Levels and Low Muscle Strength, Dynapenia, and Sarcopenia. Sci Rep 2018; 8:3573. [PMID: 29476104 PMCID: PMC5824959 DOI: 10.1038/s41598-018-21784-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 02/09/2018] [Indexed: 11/09/2022] Open
Abstract
Emerging evidences addressed an association between phosphate and muscle function. Because little attention was focused on this issue, the objective of our study was to explore the relationship of phosphate with muscle strength, dynapenia, and sarcopenia. From the National Health and Nutrition Examination Survey, a total of 7421 participants aged 20 years or older were included in our study with comprehensive examinations included anthropometric parameters, strength of the quadriceps muscle, and appendicular lean masses. Within the normal range of serum phosphate, we used quartile-based analyses to determine the potential relationships of serum phosphate with dynapenia, and sarcopenia through multivariate regression models. After adjusting for the pertinent variables, an inverse association between the serum phosphate quartiles and muscle strength was observed and the linear association was stronger than other anthropometric parameters. Notably, the significant association between phosphate and muscle strength was existed in >65 years old age group, not in 20-65 years old. The higher quartiles of phosphate had higher likelihood for predicting the presence of dynapenia rather than sarcopenia in entire population. Our study highlighted that higher quartiles of phosphate had significant association with lower muscle strength and higher risks for predicting the presence of dynapenia.
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Clinical Practices and Therapeutic Management of Mineral and Bone Disorders in Chronic Kidney Disease 4, 5 and 5D: The OCEANOS Study in Iran. Nephrourol Mon 2017. [DOI: 10.5812/numonthly.61632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Zand L, Kumar R. The Use of Vitamin D Metabolites and Analogues in the Treatment of Chronic Kidney Disease. Endocrinol Metab Clin North Am 2017; 46:983-1007. [PMID: 29080646 PMCID: PMC5977979 DOI: 10.1016/j.ecl.2017.07.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Chronic kidney disease (CKD) and end-stage renal disease (ESRD) are associated with abnormalities in bone and mineral metabolism, known as CKD-bone mineral disorder. CKD and ESRD cause skeletal abnormalities characterized by hyperparathyroidism, mixed uremic osteodystrophy, osteomalacia, adynamic bone disease, and frequently enhanced vascular and ectopic calcification. Hyperparathyroidism and mixed uremic osteodystrophy are the most common manifestations due to phosphate retention, reduced concentrations of 1,25-dihydroxyvitamin D, intestinal calcium absorption, and negative calcium balance. Treatment with 1-hydroxylated vitamin D analogues is useful.
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Affiliation(s)
- Ladan Zand
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55901, USA.
| | - Rajiv Kumar
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55901, USA; Department of Biochemistry and Molecular Biology, Mayo Clinic, 200 First Street SW, Rochester, MN 55901, USA.
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Naseri M. Hypoparathyroidism versus hyperparathyroidism in pediatric dialysis patients; a single center study. J Nephropathol 2017. [DOI: 10.15171/jnp.2017.47] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Jokihaara J, Pörsti IH, Sievänen H, Kööbi P, Kannus P, Niemelä O, Turner RT, Iwaniec UT, Järvinen TLN. Phosphate Binding with Sevelamer Preserves Mechanical Competence of Bone Despite Acidosis in Advanced Experimental Renal Insufficiency. PLoS One 2016; 11:e0163022. [PMID: 27658028 PMCID: PMC5033583 DOI: 10.1371/journal.pone.0163022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Accepted: 09/01/2016] [Indexed: 11/19/2022] Open
Abstract
Introduction Phosphate binding with sevelamer can ameliorate detrimental histomorphometric changes of bone in chronic renal insufficiency (CRI). Here we explored the effects of sevelamer-HCl treatment on bone strength and structure in experimental CRI. Methods Forty-eight 8-week-old rats were assigned to surgical 5/6 nephrectomy (CRI) or renal decapsulation (Sham). After 14 weeks of disease progression, the rats were allocated to untreated and sevelamer-treated (3% in chow) groups for 9 weeks. Then the animals were sacrificed, plasma samples collected, and femora excised for structural analysis (biomechanical testing, quantitative computed tomography). Results Sevelamer-HCl significantly reduced blood pH, and final creatinine clearance in the CRI groups ranged 30%-50% of that in the Sham group. Final plasma phosphate increased 2.4- to 2.9-fold, and parathyroid hormone 13- to 21-fold in CRI rats, with no difference between sevelamer-treated and untreated animals. In the femoral midshaft, CRI reduced cortical bone mineral density (-3%) and breaking load (-15%) (p<0.05 for all versus Sham), while sevelamer increased bone mineral density (+2%) and prevented the deleterious changes in bone. In the femoral neck, CRI reduced bone mineral density (-11%) and breaking load (-10%), while sevelamer prevented the decrease in bone mineral density (+6%) so that breaking load did not differ from controls. Conclusions In this model of stage 3–4 CRI, sevelamer-HCl treatment ameliorated the decreases in femoral midshaft and neck mineral density, and restored bone strength despite prevailing acidosis. Therefore, treatment with sevelamer can efficiently preserve mechanical competence of bone in CRI.
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Affiliation(s)
- Jarkko Jokihaara
- Department of Hand and Microsurgery, Tampere University Hospital, Tampere, Finland
- Center for Hip Health and Mobility, Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
- * E-mail:
| | | | | | - Peeter Kööbi
- Medical School, University of Tampere, Tampere, Finland
| | - Pekka Kannus
- Bone Research Group, UKK-Institute, Tampere, Finland
| | - Onni Niemelä
- Medical School, University of Tampere, Tampere, Finland
- Department of Laboratory Medicine, Seinäjoki Central Hospital Laboratory, Seinäjoki, Finland
| | - Russell T. Turner
- Skeletal Biology Laboratory, School of Biological and Population Health Sciences, Oregon State University, Corvallis, OR, United States of America
| | - Urszula T. Iwaniec
- Skeletal Biology Laboratory, School of Biological and Population Health Sciences, Oregon State University, Corvallis, OR, United States of America
| | - Teppo L. N. Järvinen
- Center for Hip Health and Mobility, Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
- Department of Orthopaedics and Traumatology, University of Helsinki, Helsinki, Finland
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Vrdoljak I, Panjkota Krbavčić I, Bituh M, Leko N, Pavlović D, Vrdoljak Margeta T. The impact of education and cooking methods on serum phosphate levels in patients on hemodialysis: 1-year study. Hemodial Int 2016; 21:256-264. [DOI: 10.1111/hdi.12468] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 07/13/2016] [Indexed: 12/21/2022]
Affiliation(s)
- Ivica Vrdoljak
- Department of Dietetics and Nutrition; General Hospital “Dr Josip Benčević”; Slavonski Brod Croatia
| | - Ines Panjkota Krbavčić
- Faculty of Food Technology and Biotechnology, Department of Food Quality Control; University of Zagreb; Zagreb Croatia
| | - Martina Bituh
- Faculty of Food Technology and Biotechnology, Department of Food Quality Control; University of Zagreb; Zagreb Croatia
| | - Ninoslav Leko
- Department of Nephrology and Dialysis; General Hospital “Dr Josip Benčević”; Slavonski Brod Croatia
| | - Draško Pavlović
- Department of Nephrology and Dialysis; Sestre Milosrdnice University Hospital; Zagreb Croatia
| | - Tea Vrdoljak Margeta
- Department of Nephrology and Dialysis; General Hospital “Dr Josip Benčević”; Slavonski Brod Croatia
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Arévalo-Lorido JC, Carretero-Gómez J, García-Sánchez F, Maciá-Botejara E, Ramiro-Lozano JM, Masero-Carretero A, Robles NR, Bureo-Dacal JC. Secondary hyperparathyroidism prevalence and profile, between diabetic and non-diabetic patients with stage 3 to 4 chronic kidney disease attended in internal medicine wards. MiPTH study. Diabetes Metab Syndr 2016; 10:S16-S21. [PMID: 26916015 DOI: 10.1016/j.dsx.2016.01.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 01/09/2016] [Indexed: 11/25/2022]
Abstract
AIMS Secondary hyperparathyroidism (SHPTH) is a leading cause of renal osteodystrophy, and an independent risk factor for all-cause and cardiovascular mortality. Our aim is to establish differences in prevalence and profile of SHPTH, regarding diabetics or non-diabetics with chronic kidney disease (CKD). METHODS Cross-sectional multicenter study which included patients with stages 3 to 4 CKD. SHPTH was considered when the intact PTH levels (iPTH) were equal or higher than 70pg/ml. We divided the sample into two groups (diabetics and non-diabetics). We used robust statistical methods. RESULTS 409 patients (214 diabetics) were studied. HPTH was found in 60.4% of diabetics vs 65% of non-diabetics (P=0.42). Diabetics with HPTH were younger (79.5 vs 82.3 years-old, P=0.005), and had more hypertension (P=0.0014), dyslipidemia (P=0.0001) and comorbidities. In multivariate analysis, we found a significant relationship in case of diabetics, with age (OR: 1.04, 95%CI 1.005-1.09 P=0.02 ), and with statins treatment (OR 2.3, 95%CI 1.17-4.54, P=0.01). DISCUSSION The prevalence of SHPTH between the groups was similar, however, diabetics had more presence of hypertension and dyslipidemia, and SHPTH in this case was also related with moderate microalbuminuria and lower levels of vitamin D. An association with statins was also found in this group.
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Shilo V, Ben-Dov IZ, Nechama M, Silver J, Naveh-Many T. Parathyroid-specific deletion of dicer-dependent microRNAs abrogates the response of the parathyroid to acute and chronic hypocalcemia and uremia. FASEB J 2015; 29:3964-76. [PMID: 26054367 DOI: 10.1096/fj.15-274191] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 05/26/2015] [Indexed: 11/11/2022]
Abstract
MicroRNAs (miRNAs) down-regulate gene expression and have vital roles in biology but their functions in the parathyroid are unexplored. To study this, we generated parathyroid-specific Dicer1 knockout (PT-Dicer(-/-) ) mice where parathyroid miRNA maturation is blocked. Remarkably, the PT-Dicer(-/-) mice did not increase serum parathyroid hormone (PTH) in response to acute hypocalcemia compared with the >5-fold increase in controls. PT-Dicer(-/-) glands cultured in low-calcium medium secreted 5-fold less PTH at 1.5 h than controls. Chronic hypocalcemia increased serum PTH >4-fold less in PT-Dicer(-/-) mice compared with control mice with no increase in PTH mRNA levels and parathyroid cell proliferation compared with the 2- to 3-fold increase in hypocalcemic controls. Moreover, uremic PT-Dicer(-/-) mice increased serum PTH and FGF23 significantly less than uremic controls. Therefore, stimulation of the parathyroid by both hypocalcemia and uremia is dependent upon intact dicer function and miRNAs. In contrast, the PT-Dicer(-/-) mice responded normally to activation of the parathyroid calcium-sensing receptor (Casr) by both hypercalcemia and a calcimimetic that decreases PTH secretion, demonstrating that they are dicer-independent. Therefore, miRNAs are essential for the response of the parathyroid to both acute and chronic hypocalcemia and uremia, the major stimuli for PTH secretion.
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Affiliation(s)
- Vitali Shilo
- *Minerva Center for Calcium and Bone Metabolism, Nephrology Services, Hadassah Hebrew University Medical Center, Jerusalem, Israel; and Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Iddo Z Ben-Dov
- *Minerva Center for Calcium and Bone Metabolism, Nephrology Services, Hadassah Hebrew University Medical Center, Jerusalem, Israel; and Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Morris Nechama
- *Minerva Center for Calcium and Bone Metabolism, Nephrology Services, Hadassah Hebrew University Medical Center, Jerusalem, Israel; and Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Justin Silver
- *Minerva Center for Calcium and Bone Metabolism, Nephrology Services, Hadassah Hebrew University Medical Center, Jerusalem, Israel; and Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Tally Naveh-Many
- *Minerva Center for Calcium and Bone Metabolism, Nephrology Services, Hadassah Hebrew University Medical Center, Jerusalem, Israel; and Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Vhora R, Munde A, Bale C, Kakrani A. Correlation of serum parathyroid hormone with mineral bone disease in chronic kidney disease patients. MEDICAL JOURNAL OF DR. D.Y. PATIL UNIVERSITY 2015. [DOI: 10.4103/0975-2870.169947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Wu S, Wang J, Wang F, Wang L. Oral active vitamin d treatment and mortality in maintenance hemodialysis patients. Cardiorenal Med 2014; 4:217-24. [PMID: 25737686 DOI: 10.1159/000368203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 09/02/2014] [Indexed: 12/17/2022] Open
Abstract
AIMS To analyze the relationship between oral active vitamin D treatment and mortality in maintenance hemodialysis (MHD) patients. METHODS We examined the association of oral calcitriol treatment with mortality in 156 MHD patients (80 men and 76 women; mean age: 59 ± 15 years). The survival analysis of all-cause and cardiovascular mortality was performed using the Kaplan-Meier survival and Cox proportional-hazards analyses. RESULTS In all, 108 of the 156 patients received active vitamin D treatment. The intact parathyroid hormone level was obviously lower in the patients who received active vitamin D treatment than in those who did not. Throughout the whole follow-up, overall mortality was 16.7% (26 deaths, 13 in each group). The cardiovascular mortality rates were 14.6% (8/48) in the control group and 4.6% (5/108) in the calcitriol group. The crude analysis of all-cause and cardiovascular mortality using the Kaplan-Meier curve showed a significant reduction in mortality risk for patients who received oral active vitamin D compared with those who did not receive it (p = 0.015 and 0.026, respectively). Cox's regression analysis showed that active vitamin D treatment was associated with a significantly lower risk of all-cause mortality (RR = 0.399, 95% CI 0.185-0.862, p = 0.019) and cardiovascular mortality (RR = 0.295, 95% CI 0.094-0.93, p = 0.037). However, after adjusting for potential confounding variables, oral active vitamin D therapy was no longer clearly associated with a lower risk of either all-cause or cardiovascular mortality. CONCLUSION Oral active vitamin D treatment was associated with improved survival in MHD patients. However, this survival benefit was smaller than previously reported, and a large cohort study should be performed.
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Affiliation(s)
- Shukun Wu
- Department of Nephrology, Sichuan Academy of Medical Sciences, Sichuan Provincial People's Hospital, Chengdu, PR China
| | - Junru Wang
- Department of Nephrology, Sichuan Academy of Medical Sciences, Sichuan Provincial People's Hospital, Chengdu, PR China
| | - Fang Wang
- Department of Nephrology, Sichuan Academy of Medical Sciences, Sichuan Provincial People's Hospital, Chengdu, PR China
| | - Li Wang
- Department of Nephrology, Sichuan Academy of Medical Sciences, Sichuan Provincial People's Hospital, Chengdu, PR China
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Farrand KF, Copley JB, Heise J, Fridman M, Keith MS, Poole L. Analysis of serum phosphate control and phosphate binder utilization in incident hemodialysis patients. Int J Nephrol Renovasc Dis 2014; 7:261-9. [PMID: 25045277 PMCID: PMC4094578 DOI: 10.2147/ijnrd.s58037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
The purpose of this study was to conduct a retrospective analysis of serum phosphate level variability in patients new to hemodialysis (HD) and to identify patient characteristics associated with this variability. The medical records of 47,742 incident HD patients attending US outpatient dialysis centers between January 1, 2006 and March 31, 2009 were analyzed. Monthly mean serum phosphate levels determined over a 6-month evaluation period (months 4–9 after HD initiation) were assigned to one of three strata: low (<1.13 mmol/L [<3.5 mg/dL]); target (1.13–1.78 mmol/L [3.5–5.5 mg/dL]); or high (>1.78 mmol/L [>5.5 mg/dL]). Patients were classified into one of six serum phosphate variability groups based on variability among monthly mean phosphate levels over the 6-month evaluation period: consistently target; consistently high; high-to-target; high-to-low; target-to-low; or consistently low. Only 15% of patients (consistently target group) maintained monthly mean serum phosphate levels within the target range throughout the 6-month evaluation period. Age, Charlson comorbidity index, serum phosphate, and intact parathyroid hormone levels prior to HD initiation were strongly associated (P<0.001) with serum phosphate levels after HD initiation. Overall patient-reported phosphate binder usage increased from 35% at baseline to 52% at end of study. The low proportion of patients achieving target phosphate levels and low rates of phosphate binder usage observed during the study suggest that alternative strategies could be developed to control serum phosphate levels. Possible strategies that might be incorporated to help improve the management of hyperphosphatemia in incident HD patients include dietary modification, dialysis optimization, and earlier and sustained use of phosphate binders.
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Patterns in the parathyroid response to sodium bicarbonate infusion test in healthy volunteers. BIOMED RESEARCH INTERNATIONAL 2014; 2014:704394. [PMID: 24804234 PMCID: PMC3997070 DOI: 10.1155/2014/704394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 03/24/2014] [Indexed: 12/14/2022]
Abstract
Background. The sodium bicarbonate infusion test evaluates the function of the parathyroid glands. The present study aims to evaluate the range of parathyroid response in healthy individuals and the potential influence of various factors. Methods. Fifty healthy volunteers were subjected to the test. Levels of vitamin D, calcium, albumin, and PTH were measured before infusion. PTH was measured at 3, 5, 10, 30, and 60 minutes after infusion. Results. A curve describing the response of parathyroids to the test was drawn. Twenty percent of the subjects had blunted PTH response. No significant difference was observed between normal and blunted responders concerning age, BMI, baseline PTH, or calcium levels. Nonetheless, there was a significant difference in vitamin D levels (P = 0.024). Interpretation. The test is easy to perform and may be used for everyday screening. It has to be clarified whether our observations are, at least partly, produced due to the presence of individuals with a constitutively blunted response or if low levels of vitamin D decrease the ability of the parathyroids to respond. Whichever the case, PTH response of normal individuals to sodium bicarbonate infusion test is more varied than previously thought and vitamin D levels influence it.
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Eräranta A, Törmänen S, Kööbi P, Vehmas TI, Lakkisto P, Tikkanen I, Moilanen E, Niemelä O, Mustonen J, Pörsti I. Phosphate binding reduces aortic angiotensin-converting enzyme and enhances nitric oxide bioactivity in experimental renal insufficiency. Am J Nephrol 2014; 39:400-8. [PMID: 24818649 DOI: 10.1159/000362507] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Accepted: 03/26/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Disturbed calcium-phosphorus metabolism is associated with increased kidney angiotensin-converting enzyme (ACE) in experimental chronic renal insufficiency (CRI). However, information about the effects of phosphate binding and loading on vascular ACE is lacking. METHODS Fifteen weeks after 5/6 nephrectomy (NX), rats were placed on a phosphate-binding (NX+Ca, 3.0% Ca), phosphate-loading (NX+Pi, 1.5% Pi), or control diet for 12 weeks (NX and sham). RESULTS Aortic ACE, blood pressure, plasma phosphate, and parathyroid hormone were increased in the NX and NX+Pi groups, but were reduced with phosphate binding. Endothelium-mediated relaxations of isolated mesenteric conduit artery rings to acetylcholine were impaired in the NX and NX+Pi groups, but did not differ from sham in NX+Ca rats. Experiments with nitric oxide (NO) synthase inhibition in vitro suggested that the NO-mediated component of acetylcholine response was lower in the NX and NX+Pi groups, but did not differ from sham in NX+Ca rats. In all NX groups, aortic endothelial NO synthase (eNOS) was reduced, while plasma and urine concentrations of NO metabolites were increased. Aortic nitrated proteins and calcification were increased in the NX and NX+Pi groups when compared with the NX+Ca and sham groups. CONCLUSION Hypertension in the NX model of CRI was associated with reduced vasorelaxation, decreased eNOS, and increased ACE and nitrated proteins in the aorta. Phosphate binding with calcium carbonate enhanced vasorelaxation via endogenous NO and suppressed elevation of ACE and nitrated proteins, suggesting reduced vascular oxidative stress. Our findings support the view that correction of the calcium-phosphorus balance prevents CRI-induced vascular pathophysiology.
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Affiliation(s)
- Arttu Eräranta
- School of Medicine, University of Tampere, Tampere, Finland
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de Souza CM, Braosi APR, Luczyszyn SM, Olandoski M, Kotanko P, Craig RG, Trevilatto PC, Pecoits-Filho R. Association among oral health parameters, periodontitis, and its treatment and mortality in patients undergoing hemodialysis. J Periodontol 2013; 85:e169-78. [PMID: 24224959 DOI: 10.1902/jop.2013.130427] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Chronic periodontitis (CP) is a continuous, reversible source of inflammation with a potential impact on mortality in patients undergoing hemodialysis (HD). This study investigates the impact of oral health indicators, CP, and its treatment on survival rates in a group of patients undergoing HD. METHODS Clinically stable patients undergoing HD were referred for a dental examination. All patients were prospectively followed in the dialysis clinic, and all-cause mortality was recorded. Three groups of patients were analyzed: those who received CP treatment, those who did not, and patients without CP as a control group. RESULTS A total of 122 patients (79 males and 43 females, aged 23 to 77 years; mean age: 50 years; range: 23 to 77 years) were enrolled. Forty percent reported having rarely been evaluated by a dentist, and 59% had CP. There were 34 fatal events during a mean follow-up time of 64.1 ± 11.2 months. Oral factors associated with death in the univariate analysis were decreased frequency of dental visits; non-use of dental floss; increased decayed, missing, and filled teeth index; presence of CP; and absence of CP treatment. Patients with CP had a higher risk of death from all causes compared with patients without CP in the univariate analysis for untreated patients (hazard ratio 2.65 [95% confidence interval 1.06 to 6.59]; P = 0.036) and to a lesser extent for treated patients (2.36 [1.01 to 5.59]; P = 0.047). These significant differences were not maintained after adjustments for confounders in the multivariate model. CONCLUSIONS These results suggest that poor oral health, including CP, is a common finding in patients undergoing HD. The results of this study call for intervention trials to test the hypothesis that treatment of CP improves survival in maintenance of patients undergoing HD.
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Affiliation(s)
- Cleber M de Souza
- School of Health and Biosciences, Pontifical Catholic University of Parana, Curitiba, Brazil
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Riggs MM, Peterson MC, Gastonguay MR. Multiscale Physiology‐Based Modeling of Mineral Bone Disorder in Patients With Impaired Kidney Function. J Clin Pharmacol 2013; 52:45S-53S. [DOI: 10.1177/0091270011412967] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Oral calcium carbonate affects calcium but not phosphorus balance in stage 3-4 chronic kidney disease. Kidney Int 2012; 83:959-66. [PMID: 23254903 PMCID: PMC4292921 DOI: 10.1038/ki.2012.403] [Citation(s) in RCA: 158] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Patients with chronic kidney disease (CKD) are given calcium carbonate to bind dietary phosphorus, reduce phosphorus retention, and prevent negative calcium balance; however, data are limited on calcium and phosphorus balance during CKD to support this. Here, we studied eight patients with stage 3 or 4 CKD (mean estimated glomerular filtration rate 36 ml/min) who received a controlled diet with or without a calcium carbonate supplement (1500 mg/day calcium) during two 3-week balance periods in a randomized placebo-controlled cross-over design. All feces and urine were collected during weeks 2 and 3 of each balance period and fasting blood, and urine was collected at baseline and at the end of each week. Calcium kinetics were determined using oral and intravenous (45)calcium. Patients were found to be in neutral calcium and phosphorus balance while on the placebo. Calcium carbonate supplementation produced positive calcium balance, did not affect phosphorus balance, and produced only a modest reduction in urine phosphorus excretion compared with placebo. Calcium kinetics demonstrated positive net bone balance but less than overall calcium balance, suggesting soft-tissue deposition. Fasting blood and urine biochemistries of calcium and phosphate homeostasis were unaffected by calcium carbonate. Thus, the positive calcium balance produced by calcium carbonate treatment within 3 weeks cautions against its use as a phosphate binder in patients with stage 3 or 4 CKD, if these findings can be extrapolated to long-term therapy.
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Leaf DE, Wolf M. A physiologic-based approach to the evaluation of a patient with hyperphosphatemia. Am J Kidney Dis 2012; 61:330-6. [PMID: 22938849 DOI: 10.1053/j.ajkd.2012.06.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Accepted: 06/11/2012] [Indexed: 01/16/2023]
Abstract
Phosphate is required for skeletal mineralization, cellular energy regulation, synthesis of cell membranes and nucleic acids, and a variety of cell signaling pathways. Extracellular serum phosphate concentration is determined by the balance of gastrointestinal phosphate absorption, skeletal turnover, distribution in intracellular compartments, and renal phosphate excretion. An integrated system of hormones, receptors, and phosphate transporters regulates phosphate homeostasis, and a variety of hereditary and acquired perturbations in these regulators can result in hyperphosphatemia. Although kidney failure is the most common cause of hyperphosphatemia encountered by nephrologists, hyperphosphatemia that presents in patients with early stages of chronic kidney disease or normal kidney function should prompt a detailed evaluation that can be diagnostically challenging. In this teaching case, we describe a case of hyperphosphatemia out of proportion to the degree of decrease in glomerular filtration rate. We present a practical parathyroid hormone-based diagnostic approach that illustrates the current understanding of phosphate regulation in clinically meaningful terms for the practicing nephrologist. Finally, we illustrate how measurement of fibroblast growth factor 23 could be integrated in the future when the test becomes more widely available.
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Affiliation(s)
- David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Douthat WG, Chiurchiu CR, Massari PU. New options for the management of hyperparathyroidism after renal transplantation. World J Transplant 2012; 2:41-5. [PMID: 24175195 PMCID: PMC3782233 DOI: 10.5500/wjt.v2.i3.41] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Revised: 04/08/2012] [Accepted: 06/01/2012] [Indexed: 02/05/2023] Open
Abstract
The persistence and severity of hyperparathyroidism (HPT) post-renal transplantation is relatively frequent and primarily associated with the timing and its magnitude in the pre-transplant period and with the presence of parathyroid adenomas. HPT after renal transplantation is clinically manifested with hypercalcemia, hypophosphatemia, bone pain, fractures, and in more serious cases with cardiovascular calcifications that affect the survival. The primary clinical objective for patients with secondary HPT after renal transplantation is to obtain a level of parathyroid hormone (PTH) adequate to the renal transplanted function and to normalize levels of calcium, phosphorus and vitamin D. In many cases during this period, the development of hypercalcemia and/or hypophosphatemia makes it necessary to take different therapeutic measures. The use of vitamin D or its analogues has been extrapolated from the management of pre-transplant HPT obtaining variable outcomes, although its use is limited by its capacity to produce hypercalcemia. Calcimimetics are drugs that have proven be effective in reducing PTH levels in patients with HPT on dialysis and has been effective in reducing up to 50% PTH levels in moderate to severe HPT in post-renal transplantation.When HPT persists after renal transplantation and does not respond to medical treatment, invasive management by percutaneous ethanol injection therapy of parathyroid glands or parathyroidectomy should be considered. The emergence of new methods for the management of HPT expands the availability of therapeutic tools for transplant patients.
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Affiliation(s)
- Walter Guillermo Douthat
- Walter Guillermo Douthat, Carlos Raul Chiurchiu, Pablo Ulises Massari, Bone and Mineral Metabolism Section, Renal Service, Hospital Privado, Centro Médico de Córdoba, 5016 Córdoba, Argentina
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Frazão JM, Adragão T. Non-calcium-containing phosphate binders: comparing efficacy, safety, and other clinical effects. Nephron Clin Pract 2012; 120:c108-19. [PMID: 22555359 DOI: 10.1159/000337087] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Phosphate-binder therapy for hyperphosphataemia is key to the treatment of patients with chronic kidney disease (CKD)-mineral and bone disorder (MBD). Calcium-free phosphate binders are increasingly favoured since calcium-based agents potentially cause harmful calcium overload and vascular calcification that confound the benefits of reducing serum phosphorus. Several calcium-free phosphate binders are available, including the non-absorbed agent sevelamer and the absorbed agents, e.g. lanthanum and magnesium salts. Randomised controlled studies consistently show that sevelamer and lanthanum carbonate offer equivalent lowering of serum phosphorus and often effectively achieve phosphorus targets versus calcium salts, with sevelamer having a positive effect on bone disease, vascular calcification, and patient-level outcomes in dialysis patients in several trials. There is also evidence that lanthanum carbonate can improve bone health, but data are limited to its effects to vascular calcification or patient-level outcomes. Magnesium salts have also been shown to reduce serum phosphorus levels, but clear evidence is lacking on bone, vascular, or clinical outcomes. It also remains to be established whether long-term systemic accumulation of lanthanum and magnesium, in tissues including bone, has clinically relevant toxic effects. This review summarises the evidence of efficacy and safety for newer calcium-free phosphate binders in CKD-MBD management.
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Affiliation(s)
- João M Frazão
- Nephrology Department, Hospital de S. João, School of Medicine, University of Porto and Nephrology Research and Development Unit, University of Porto, Porto, Portugal.
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Eräranta A, Riutta A, Fan M, Koskela J, Tikkanen I, Lakkisto P, Niemelä O, Parkkinen J, Mustonen J, Pörsti I. Dietary phosphate binding and loading alter kidney angiotensin-converting enzyme mRNA and protein content in 5/6 nephrectomized rats. Am J Nephrol 2012; 35:401-8. [PMID: 22517117 DOI: 10.1159/000337942] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Accepted: 02/25/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND Vitamin D receptor activation with paricalcitol can modulate the transcription of renin-angiotensin system components in the surgical 5/6 nephrectomy rat model (5/6 NX) of chronic renal insufficiency. We tested the hypothesis whether dietary modification of phosphate influences kidney renin-angiotensin system gene expression at the mRNA level in 5/6 NX rats. METHODS Fifteen weeks after surgery, rats were given control diet (0.3% calcium, 0.5% phosphate), phosphate-lowering diet (3% calcium as carbonate) or high-phosphate diet (1.5%) for 12 weeks. Sham-operated rats were on control diet. RESULTS Blood pressure, plasma phosphate, parathyroid hormone, glomerulosclerosis, tubulointerstitial damage, and FGF-23 were increased in remnant kidney rats, whereas creatinine clearance was decreased. Phosphate, parathyroid hormone, glomerulosclerosis, tubulointerstitial damage, and FGF-23 were further elevated by the high-phosphate diet, but were reduced by the phosphate-lowering diet. Plasma calcium was increased with the phosphate-lowering diet and decreased with the high-phosphate diet. Remnant kidney rats on control diet showed upregulated kidney angiotensin-converting enzyme (ACE) and angiotensin (Ang) IV receptor (AT(4)) transcription, while ACE2, Ang II type 2 receptor and renin receptor transcription were downregulated in comparison with sham rats. Phosphate-lowering diet reduced whereas high-phosphate diet increased kidney ACE, and these effects were observed at both mRNA and protein levels. Dietary phosphate loading also resulted in lower AT(1a) gene transcription. CONCLUSION Dietary phosphate loading was associated with elevated kidney ACE expression, increased tissue damage and lower AT(1a) transcription in 5/6 NX rats. Phosphate binding with 3% calcium carbonate had opposite effects on ACE and kidney damage.
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Affiliation(s)
- Arttu Eräranta
- School of Medicine, University of Tampere, Tampere, Finland
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Kidney disease and vitamin D levels: 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, and VDR activation. Kidney Int Suppl (2011) 2011; 1:136-141. [PMID: 25018912 PMCID: PMC4089671 DOI: 10.1038/kisup.2011.30] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
A normal vitamin D status is essential for human health. Vitamin D deficiency is a recognized risk factor for all-cause mortality in normal individuals and in chronic kidney disease (CKD) patients. The link between vitamin D deficiency and death is a defective activation of the vitamin D receptor (VDR) by 1,25-dihydroxyvitamin D (calcitriol, the vitamin D hormone) to induce/repress genes that maintain mineral homeostasis and skeletal integrity, and prevent secondary hyperparathyroidism, hypertension, immune disorders, and renal and cardiovascular (CV) damage. The kidney is the main site for the conversion of 25-hydroxyvitamin D (25D) to circulating calcitriol, and therefore essential for the health benefits of endocrine VDR activation. The kidney is also essential for the uptake of 25D from the glomerular ultrafiltrate for its recycling to the circulation to maintain serum 25D levels, extrarenal calcitriol synthesis, and the prosurvival benefits of autocrine/paracrine VDR activation. Indeed, both calcitriol and vitamin D deficiency increase progressively in the course of CKD, and associate directly with accelerated disease progression and death. Therefore, the safe correction of calcitriol and vitamin D deficiency/insufficiency is becoming a high priority among nephrologists. This review updates the pathophysiology behind 25D and calcitriol deficiency and impaired VDR activation in CKD, the adequacy of current recommendations for vitamin D supplementation, and potential markers of the efficacy of therapy to prevent or slow the development of renal and CV lesions unrelated to parathyroid hormone suppression, a knowledge required for the design of trials to obtain evidence-based recommendations for vitamin D and calcitriol replacement at all stages of CKD.
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Abstract
In chronic kidney disease (CKD), abnormalities in vitamin D metabolism contribute to the development of mineral and skeletal disorders, elevations in parathyroid hormone (PTH), hypertension, systemic inflammation, renal and cardiovascular damage. CKD induces a progressive loss of the capacity of the kidney not only to convert 25-hydroxyvitamin D [25(OH)D] to circulating calcitriol, the vitamin D hormone, but also to maintain serum 25(OH)D levels for non-renal calcitriol synthesis. The resulting calcitriol and 25(OH)D deficiency associates directly with accelerated disease progression and death. This chapter presents our understanding of the pathophysiology behind 25(OH)D and calcitriol deficiency in CKD, of the adequacy of current recommendations for vitamin D supplementation and PTH suppression, and of potential markers of renal and cardiovascular lesions unrelated to PTH suppression, a knowledge required for the design of trials to obtain evidence-based recommendations for vitamin D and calcitriol replacement that improve outcomes at all stages of CKD.
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Affiliation(s)
- Adriana Dusso
- Division of Experimental Nephrology, IRBLleida (Lleida Institute for Biomedical Research), Avda Rovira Roure 80, Lleida, Spain.
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Jean G, Souberbielle JC, Lorriaux C, Mayor B, Hurot JM, Deleaval P, Chazot C. [Clinical and biological forms of secondary hyperparathyroidism in dialysis patients]. Nephrol Ther 2011; 8:35-40. [PMID: 21741337 DOI: 10.1016/j.nephro.2011.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Revised: 05/27/2011] [Accepted: 05/29/2011] [Indexed: 01/31/2023]
Abstract
The diagnosis and treatment of hyperparathyroidism (HPT) are not yet well standardized in chronic renal failure patients. The aim of this study was to identify the main types of HPT on the basis of clinical and biological findings in a haemodialysis population. Between 2004 and 2010, all patients undergoing haemodialysis were observed and treated using the same strategy: conventional therapy with vitamin D supplements, phosphate binders, dialysate calcium adjusted to serum parathyroid hormone (PTH) level and calcitriol analogues (CA), along with regular bone marker analysis. Wherever required, cinacalcet (CC) was administered and parathyroidectomy (PTX) was performed. Of the 520 patients, 158 were classified as having HPT (30%) with a serum PTH level greater than 300 pg/mL. From this population, we identified five main types of HPT: (1) HPT with 'no bone impact' had normal or low bone marker levels (n=28, 17.7%); (2) 'secondary' HPT had elevated bone marker levels, but showed favorable response to CT (n=59, 37.7%); (3) 'tertiary' HPT was accompanied with hypercalcemia and required CC or PTX in case of CT failure (n=11, 6.9%); (4) 'mixed' HPT could not be completely treated with CT and required CC or PTX (n=57, 36%); (5) 'resistant' HPT did not show hypercalcemia, but required PTX after CT and CC failure (n=3, 1.8%). CC was prescribed in 51% cases, CA in 76%, and PTX in 7% of cases. We typified HPT on the basis of physiopathology and stages of HPT progression. Further studies on HPT that focus on bone marker levels are required to establish well-defined treatment strategies. In our study, HPT cases did not show uniform findings in Hémodialyse (HD) patients because of the variation in the stages of the disease at the time of diagnosis.
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Affiliation(s)
- Guillaume Jean
- Centre de rein artificiel, Nephrocare, 42, avenue du 8-mai-1945, 69160 Tassin la Demi-lune, France.
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Youssef DA, El Abbassi AM, Cutchins DC, Chhabra S, Peiris AN. Vitamin D deficiency: Implications for acute care in the elderly and in patients with chronic illness. Geriatr Gerontol Int 2011; 11:395-407. [DOI: 10.1111/j.1447-0594.2011.00716.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Qunibi W, Winkelmayer WC, Solomon R, Moustafa M, Kessler P, Ho CH, Greenberg J, Diaz-Buxo JA. A randomized, double-blind, placebo-controlled trial of calcium acetate on serum phosphorus concentrations in patients with advanced non-dialysis-dependent chronic kidney disease. BMC Nephrol 2011; 12:9. [PMID: 21324193 PMCID: PMC3055808 DOI: 10.1186/1471-2369-12-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2010] [Accepted: 02/16/2011] [Indexed: 11/20/2022] Open
Abstract
Background Hyperphosphatemia in patients with chronic kidney disease (CKD) contributes to secondary hyperparathyroidism, soft tissue calcification, and increased mortality risk. This trial was conducted to examine the efficacy and safety of calcium acetate in controlling serum phosphorus in pre-dialysis patients with CKD. Methods In this randomized, double-blind, placebo-controlled trial, 110 nondialyzed patients from 34 sites with estimated GFR < 30 mL/min/1.73 m2 and serum phosphorus > 4.5 mg/dL were randomized to calcium acetate or placebo for 12 weeks. The dose of study drugs was titrated to achieve target serum phosphorus of 2.7-4.5 mg/dL. Serum phosphorus, calcium, iPTH, bicarbonate and serum albumin were measured at baseline and every 2 weeks for the 12 week study period. The primary efficacy endpoint was serum phosphorus at 12 weeks. Secondary endpoints were to measure serum calcium and intact parathyroid hormone (iPTH) levels. Results At 12 weeks, serum phosphorus concentration was significantly lower in the calcium acetate group compared to the placebo group (4.4 ± 1.2 mg/dL vs. 5.1 ± 1.4 mg/dL; p = 0.04). The albumin-adjusted serum calcium concentration was significantly higher (9.5 ± 0.8 vs. 8.8 ± 0.8; p < 0.001) and iPTH was significantly lower in the calcium acetate group compared to placebo (150 ± 157 vs. 351 ± 292 pg/mL respectively; p < 0.001). At 12 weeks, the proportions of subjects who had hypocalcemia were 5.4% and 19.5% for the calcium acetate and the placebo groups, respectively, while the proportions of those with hypercalcemia were 13.5% and 0%, respectively. Adverse events did not differ between the treatment groups. Conclusions In CKD patients not yet on dialysis, calcium acetate was effective in reducing serum phosphorus and iPTH over a 12 week period. Trial Registration www.clinicaltrials.gov NCT00211978.
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Affiliation(s)
- Wajeh Qunibi
- Department of Medicine, University of Texas Health Sciences Center, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA.
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Defective renal maintenance of the vitamin D endocrine system impairs vitamin D renoprotection: a downward spiral in kidney disease. Kidney Int 2011; 79:715-29. [PMID: 21270766 DOI: 10.1038/ki.2010.543] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In kidney disease, the progressive loss of renal capacity to produce calcitriol, the vitamin D hormone, is a key contributor to elevations in parathyroid hormone (PTH) and mineral and skeletal disorders predisposing to renal and cardiovascular damage, ectopic calcifications, and high mortality rates. Thus, the safe correction of calcitriol deficiency to suppress PTH has been the treatment of choice for decades. However, recent epidemiological and experimental data suggest that calcitriol replacement may improve outcomes through renal and cardioprotective actions unrelated to PTH suppression. Furthermore, a striking incidence of vitamin D deficiency occurs in kidney disease and associates more strongly than calcitriol deficiency with a higher risk for kidney disease progression and death. Despite the translational relevance of these findings, no prospective trials are currently available in support of the efficacy of vitamin D supplementation and/or calcitriol replacement to safely halt/moderate renal disease progression. This review updates the pathophysiology behind the vicious cycle by which kidney injury impairs the maintenance of normal vitamin D and calcitriol levels, which in turn impedes vitamin D/calcitriol renoprotective actions, a requirement for the design of prospective trials to improve current recommendations for vitamin D interventions at all stages of kidney disease.
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Lynch KE, Lynch R, Curhan GC, Brunelli SM. Prescribed dietary phosphate restriction and survival among hemodialysis patients. Clin J Am Soc Nephrol 2010; 6:620-9. [PMID: 21148246 DOI: 10.2215/cjn.04620510] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Hyperphosphatemia is common among hemodialysis patients. Although prescribed dietary phosphate restriction is a recommended therapy, little is known about the long-term effects on survival. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a post hoc analysis of data from the Hemodialysis Study (n = 1751). Prescribed dietary phosphate was recorded at baseline and annually thereafter. Marginal structural proportional hazard models were fit to estimate the adjusted association between dietary phosphate restriction and mortality in the setting of time-dependent confounding. RESULTS At baseline, prescribed daily phosphate was restricted to levels ≤ 870, 871 to 999, 1000, 1001 to 2000 mg, and not restricted in 300, 314, 307, 297, and 533 participants, respectively. More restrictive prescribed dietary phosphate was associated with poorer indices of nutritional status on baseline analyses and a persistently greater need for nutritional supplementation but not longitudinal changes in caloric or protein intake. On marginal structural analysis, there was a stepwise trend toward greater survival with more liberal phosphate prescription, which reached statistical significance among subjects prescribed 1001 to 2000 mg/d and those with no specified phosphate restriction: hazard ratios (95% CIs) 0.73 (0.54 to 0.97) and 0.71 (0.55 to 0.92), respectively. Subgroup analysis suggested a more pronounced survival benefit of liberal dietary phosphate prescription among nonblacks, participants without hyperphosphatemia, and those not receiving activated vitamin D. CONCLUSIONS Prescribed dietary phosphate restriction is not associated with improved survival among prevalent hemodialysis patients, and increased level of restriction may be associated with greater mortality particularly in some subgroups.
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Affiliation(s)
- Katherine E Lynch
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Peterson MC, Riggs MM. A physiologically based mathematical model of integrated calcium homeostasis and bone remodeling. Bone 2010; 46:49-63. [PMID: 19732857 DOI: 10.1016/j.bone.2009.08.053] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2009] [Revised: 08/24/2009] [Accepted: 08/26/2009] [Indexed: 12/30/2022]
Abstract
Bone biology is physiologically complex and intimately linked to calcium homeostasis. The literature provides a wealth of qualitative and/or quantitative descriptions of cellular mechanisms, bone dynamics, associated organ dynamics, related disease sequela, and results of therapeutic interventions. We present a physiologically based mathematical model of integrated calcium homeostasis and bone biology constructed from literature data. The model includes relevant cellular aspects with major controlling mechanisms for bone remodeling and calcium homeostasis and appropriately describes a broad range of clinical and therapeutic conditions. These include changes in plasma parathyroid hormone (PTH), calcitriol, calcium and phosphate (PO4), and bone-remodeling markers as manifested by hypoparathyroidism and hyperparathyroidism, renal insufficiency, daily PTH 1-34 administration, and receptor activator of NF-kappaB ligand (RANKL) inhibition. This model highlights the utility of systems approaches to physiologic modeling in the bone field. The presented bone and calcium homeostasis model provides an integrated mathematical construct to conduct hypothesis testing of influential system aspects, to visualize elements of this complex endocrine system, and to continue to build upon iteratively with the results of ongoing scientific research.
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Affiliation(s)
- Mark C Peterson
- Amgen, Inc., One Amgen Center Drive, MS 28-3-B, Thousand Oaks, CA 91320, USA.
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Tamagawa K, Nakayama-Imaohji H, Wakimoto S, Ichimura M, Kuwahara T. Utilization of titanium oxide-like compound as an inorganic phosphate adsorbent for the control of serum phosphate level in chronic renal failure. THE JOURNAL OF MEDICAL INVESTIGATION 2010; 57:275-83. [DOI: 10.2152/jmi.57.275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Kazuhiko Tamagawa
- Department of Immunology and Parasitology, Institute of Health Biosciences, the University of Tokushima Graduate School
- Tomita Pharmaceutical Co. Ltd.,
| | - Haruyuki Nakayama-Imaohji
- Department of Immunology and Parasitology, Institute of Health Biosciences, the University of Tokushima Graduate School
| | - Shin Wakimoto
- Department of Immunology and Parasitology, Institute of Health Biosciences, the University of Tokushima Graduate School
| | - Minoru Ichimura
- Department of Immunology and Parasitology, Institute of Health Biosciences, the University of Tokushima Graduate School
| | - Tomomi Kuwahara
- Department of Immunology and Parasitology, Institute of Health Biosciences, the University of Tokushima Graduate School
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Goldsmith D, Kothawala P, Chalian A, Bernal M, Robbins S, Covic A. Systematic Review of the Evidence Underlying the Association Between Mineral Metabolism Disturbances and Risk of Fracture and Need for Parathyroidectomy in CKD. Am J Kidney Dis 2009; 53:1002-13. [DOI: 10.1053/j.ajkd.2009.02.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2008] [Accepted: 02/13/2009] [Indexed: 11/11/2022]
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Savica V, Calò LA, Monardo P, Davis PA, Granata A, Santoro D, Savica R, Musolino R, Comelli MC, Bellinghieri G. Salivary phosphate-binding chewing gum reduces hyperphosphatemia in dialysis patients. J Am Soc Nephrol 2008; 20:639-44. [PMID: 19020004 DOI: 10.1681/asn.2008020130] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
In uremic patients, hyperphosphatemia is associated with cardiovascular calcification and increased cardiovascular mortality. Despite the use of phosphate binders, only half of hemodialysis (HD) patients achieve recommended serum phosphate levels. A hyperphosphoric salivary content, which correlates linearly with serum phosphate, has been reported in HD patients. We hypothesized that binding salivary phosphate during periods of fasting in addition to using phosphate binders with meals could improve the treatment of hyperphosphatemia. We assessed the phosphate-binding capacity of the natural polymer chitosan by (31)P nuclear magnetic resonance and established that 10 and 20% (wt/vol) middle viscosity chitosan solutions bind 30 and 50% of the phosphate contained in PBS, respectively. Thirteen HD patients with serum phosphate levels >6.0 mg/dl despite treatment with sevelamer hydrochloride chewed 20 mg of chitosan-loaded chewing gum twice daily for 2 wk at fast in addition to their prescribed phosphate-binding regimen. Salivary phosphate and serum phosphate significantly decreased during the first week of chewing; by the end of 2 wk, salivary phosphate decreased 55% from baseline (73.21 +/- 19.19 to 33.19 +/- 6.53; P < 0.00001), and serum phosphate decreased 31% from baseline (7.60 +/- 0.91 to 5.25 +/- 0.89 mg/dl; P < 0.00001). Salivary phosphate returned to baseline by day 15 after discontinuing the chewing gum, whereas serum phosphate levels took 30 d to return to baseline. Parathyroid hormone and serum calcium concentrations were not affected by the gum. In conclusion, adding salivary phosphate binding to traditional phosphate binders could be a useful approach for improving treatment of hyperphosphatemia in HD patients.
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Affiliation(s)
- Vincenzo Savica
- Department of Nephrology, Clinica Medica, University of Messina, Messina, Italy
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Wetmore JB, Quarles LD. Treatment of secondary hyperparathyroidism in kidney disease: what we know and do not know about use of calcimimetics and vitamin D analogs. Int J Nephrol Renovasc Dis 2008; 1:5-17. [PMID: 21694914 PMCID: PMC3108756 DOI: 10.2147/ijnrd.s4368] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
There is a growing understanding of the pathophysiology of secondary hyperparathyroidism (SHPT) and a recent emergence of new agents for SHPT treatment in patients with advanced kidney disease. At the same time, appreciation that mineral metabolic derangements promote vascular calcification and contribute to excess mortality, along with recognition of potentially important “non-classical” actions of vitamin D, have prompted the nephrology community to reexamine the use of various SHPT treatments, such as activated vitamin D sterols, phosphate binders, and calcimimetics. In this review, the evidence for treatment of SHPT with calcimimetics and vitamin D analogs is evaluated, with particular consideration given to recent clinical trials that have reported encouraging findings with cinacalcet use. Additionally, several controversies in the pathogenesis and treatment of SHPT are explored. The proposition that calcitriol deficiency is a true pathological state is challenged, the relative importance of the vitamin D receptor and the calcium sensing receptor in parathyroid gland function is summarized, and the potential relevance of non-classical actions of vitamin D for patients with advanced renal disease is examined. Taken collectively, the balance of evidence now supports a treatment paradigm in which calcimimetics are the most appropriate primary treatment for SHPT in the majority of end stage renal disease patients, but which nevertheless acknowledges an important role for modest doses of activated vitamin D sterols.
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Affiliation(s)
- James B Wetmore
- Department of Medicine, Division of Nephrology, University of Kansas Medical Center, Kansas City, KS, USA
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