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Kucinick M, Charles KE, Carter K, Edwards J, Costlow C, Wilkerson M, Seddon D, Marancik D. Comparative plasma biochemistry analyte data in nesting leatherback ( Dermochelys coriacea), foraging green ( Chelonia mydas) and foraging and nesting hawksbill ( Eretmochelys imbricata) sea turtles in Grenada, West Indies. CONSERVATION PHYSIOLOGY 2024; 12:coae028. [PMID: 38765884 PMCID: PMC11099945 DOI: 10.1093/conphys/coae028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 03/12/2024] [Accepted: 04/22/2024] [Indexed: 05/22/2024]
Abstract
Blood biochemistry represents a minimally invasive tool for monitoring sea turtle health, assessing injured sea turtles and supporting conservation strategies. In Grenada, West Indies, plasma biochemical variables were examined in 33 nesting leatherback (Dermochelys coriacea), 49 foraging green (Chelonia mydas), 49 foraging hawksbill (Eretmochelys imbricata) and 12 nesting hawksbill sea turtles sampled between 2017 and 2022. Plasma biochemistry reference intervals are described herein except for nesting hawksbills, which are represented by descriptive statistics due to the low sample size. Select analyte concentrations were positively correlated with curved carapace length in leatherbacks (chloride), green turtles (total protein, albumin and globulin) and foraging hawksbills (total protein, albumin and phosphorus). Cholesterol (7.8 mmol/l ± 1.6 SD) and triglyceride (6.9 mmol/l ± 1.9 SD) concentrations were significantly higher in leatherbacks compared to foraging green turtles, foraging hawksbills and nesting hawksbills (P < 0.001 for all). Cholesterol was significantly higher in nesting hawksbills compared to foraging green turtles (P = 0.050) and foraging hawksbills (P = 0.050). Foraging hawksbills demonstrated significantly higher aspartate transaminase activities than leatherbacks (P = 0.002), green turtles (P = 0.009) and nesting hawksbills (P < 0.001). Biochemical results provide baseline population health data and support guidance for treatments during clinical sea turtle rehabilitation efforts. They also provide insight into species-specific physiologic differences and preludes further studies to better characterize the impacts of life-stage class on biochemistry reference intervals to better support wild sea turtle populations in Grenada.
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Affiliation(s)
- Madison Kucinick
- Department of Pathobiology, St. George’s University School of Veterinary Medicine, True Blue, Grenada, West Indies
| | | | - Kenrith Carter
- Ocean Spirits, Inc, Levera, Grenada, West Indies
- Dr Carter Veterinary Services, St. David's, Grenada, West Indies
| | - Jonnel Edwards
- Department of Pathobiology, St. George’s University School of Veterinary Medicine, True Blue, Grenada, West Indies
| | - Catherine Costlow
- Department of Pathobiology, St. George’s University School of Veterinary Medicine, True Blue, Grenada, West Indies
| | - Melinda Wilkerson
- Department of Pathobiology, St. George’s University School of Veterinary Medicine, True Blue, Grenada, West Indies
| | - Dawn Seddon
- Department of Pathobiology, St. George’s University School of Veterinary Medicine, True Blue, Grenada, West Indies
| | - David Marancik
- Department of Pathobiology, St. George’s University School of Veterinary Medicine, True Blue, Grenada, West Indies
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Magagnoli L, Cozzolino M, Caskey FJ, Evans M, Torino C, Porto G, Szymczak M, Krajewska M, Drechsler C, Stenvinkel P, Pippias M, Dekker FW, de Rooij ENM, Wanner C, Chesnaye NC, Jager KJ. Association between CKD-MBD and mortality in older patients with advanced CKD-results from the EQUAL study. Nephrol Dial Transplant 2023; 38:2562-2575. [PMID: 37230954 PMCID: PMC10615632 DOI: 10.1093/ndt/gfad100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Chronic kidney disease-mineral and bone disorder (CKD-MBD) is a common complication of CKD; it is associated with higher mortality in dialysis patients, while its impact in non-dialysis patients remains mostly unknown. We investigated the associations between parathyroid hormone (PTH), phosphate and calcium (and their interactions), and all-cause, cardiovascular (CV) and non-CV mortality in older non-dialysis patients with advanced CKD. METHODS We used data from the European Quality study, which includes patients aged ≥65 years with estimated glomerular filtration rate ≤20 mL/min/1.73 m2 from six European countries. Sequentially adjusted Cox models were used to assess the association between baseline and time-dependent CKD-MBD biomarkers and all-cause, CV and non-CV mortality. Effect modification between biomarkers was also assessed. RESULTS In 1294 patients, the prevalence of CKD-MBD at baseline was 94%. Both PTH [adjusted hazard ratio (aHR) 1.12, 95% confidence interval (CI) 1.03-1.23, P = .01] and phosphate (aHR 1.35, 95% CI 1.00-1.84, P = .05), but not calcium (aHR 1.11, 95% CI 0.57-2.17, P = .76), were associated with all-cause mortality. Calcium was not independently associated with mortality, but modified the effect of phosphate, with the highest mortality risk found in patients with both hypercalcemia and hyperphosphatemia. PTH level was associated with CV mortality, but not with non-CV mortality, whereas phosphate was associated with both CV and non-CV mortality in most models. CONCLUSIONS CKD-MBD is very common in older non-dialysis patients with advanced CKD. PTH and phosphate are independently associated with all-cause mortality in this population. While PTH level is only associated with CV mortality, phosphate seems to be associated with both CV and non-CV mortality.
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Affiliation(s)
- Lorenza Magagnoli
- University of Milan, Department of Health Sciences, Milan, Italy
- ASST Santi Paolo e Carlo, Renal Division, Milan, Italy
| | - Mario Cozzolino
- University of Milan, Department of Health Sciences, Milan, Italy
- ASST Santi Paolo e Carlo, Renal Division, Milan, Italy
| | - Fergus J Caskey
- University of Bristol, Population Health Sciences, Bristol, UK
- North Bristol NHS Trust, Renal Unit, Bristol, UK
| | - Marie Evans
- Karolinska Institutet, Department of Clinical Intervention and Technology (CLINTEC), Stockholm, Sweden
| | - Claudia Torino
- Istituto di Fisiologia Clinica Consiglio Nazionale delle Ricerche (IFC-CNR), Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension, Reggio Calabria, Italy (IT)
| | - Gaetana Porto
- G.O.M., Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria, Italy
| | - Maciej Szymczak
- Wroclaw Medical University, Department of Nephrology and Transplantation Medicine, Wroclaw, Poland
| | - Magdalena Krajewska
- Wroclaw Medical University, Department of Nephrology and Transplantation Medicine, Wroclaw, Poland
| | | | - Peter Stenvinkel
- Karolinska Institutet, Department of Clinical Intervention and Technology (CLINTEC), Stockholm, Sweden
| | - Maria Pippias
- University of Bristol, Population Health Sciences, Bristol, UK
- North Bristol NHS Trust, Renal Unit, Bristol, UK
| | - Friedo W Dekker
- Leiden University Medical Center, Department of Clinical Epidemiology, Leiden, The Netherlands
| | - Esther N M de Rooij
- Leiden University Medical Center, Department of Clinical Epidemiology, Leiden, The Netherlands
| | - Christoph Wanner
- University Hospital Würzburg, Division of Nephrology, Würzburg, Germany
| | - Nicholas C Chesnaye
- Amsterdam UMC location AMC, Medical Informatics, ERA Registry, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, The Netherlands
| | - Kitty J Jager
- Amsterdam UMC location AMC, Medical Informatics, ERA Registry, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, The Netherlands
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Phylactou M, Comninos AN, Salih A, Labib M, Eng PC, Clarke SA, Moore P, Tan T, Cegla J, Dhillo WS, Abbara A. Derivation and comparison of formulae for the adjustment of total calcium. Front Endocrinol (Lausanne) 2023; 14:1070443. [PMID: 37251673 PMCID: PMC10213740 DOI: 10.3389/fendo.2023.1070443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 04/18/2023] [Indexed: 05/31/2023] Open
Abstract
Background Free ionized calcium (Ca2+) is the biologically active component of total calcium (TCa) and hence responsible for its biological action. TCa is routinely adjusted for albumin using several formulae (e.g. James, Orell, Payne and Berry) to more closely reflect Ca2+. Here, we derive a novel formula to estimate Ca2+ and compare its performance to established formulae. Methods Cohort for prediction of Ca2+: 2806 serum samples (TCa) taken contemporaneously with blood gas samples (Ca2+) at Imperial College Healthcare NHS Trust were used to derive formulae to estimate Ca2+ using multivariable linear regression. Cohort for prediction of PTH: Performance of novel and existing formulae to predict PTH in 5510 patients was determined by Spearman correlation. Results Ca2+ prediction Cohort: Adjusted calcium (r2 = 0.269) was less strongly associated with Ca2+, than TCa (r2 = 0.314). Prediction of Ca2+ from a newly derived formula incorporating TCa, potassium, albumin, and hematocrit had an improved r2 of 0.327, whereas inclusion of all available parameters increased the r2 further to 0.364. Of the established formulae, James performed best in predicting Ca2+ (r2 = 0.27). PTH prediction cohort: Berry resulted in higher whereas Orell in lower adjusted calcium levels. Prediction of PTH was strongest in the setting of hypercalcemia, with James having the highest Spearman correlation coefficient (+0.496) similar to including all parameters (+0.499). Conclusion Adjustment of calcium for albumin using established formulae does not always outperform unadjusted TCa in the reflection of Ca2+. Further prospective studies are needed to optimise adjustment of TCa and to establish bounds for validity.
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Affiliation(s)
- Maria Phylactou
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, United Kingdom
- Department of Endocrinology, Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Alexander N. Comninos
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, United Kingdom
- Department of Endocrinology, Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Ahmed Salih
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, United Kingdom
| | - Marina Labib
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, United Kingdom
| | - Pei Chia Eng
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, United Kingdom
- Department of Endocrinology, Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Sophie A. Clarke
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, United Kingdom
- Department of Endocrinology, Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Pope Moore
- Department of Clinical Biochemistry, North West London Pathology, Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Tricia Tan
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, United Kingdom
- Department of Endocrinology, Imperial College Healthcare National Health Service Trust, London, United Kingdom
- Department of Clinical Biochemistry, North West London Pathology, Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Jaimini Cegla
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, United Kingdom
- Department of Endocrinology, Imperial College Healthcare National Health Service Trust, London, United Kingdom
- Department of Clinical Biochemistry, North West London Pathology, Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Waljit S. Dhillo
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, United Kingdom
- Department of Endocrinology, Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Ali Abbara
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, United Kingdom
- Department of Endocrinology, Imperial College Healthcare National Health Service Trust, London, United Kingdom
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Bancal C, Salipante F, Hannas N, Lumbroso S, Cavalier E, De Brauwere DP. A new approach to assessing calcium status via a machine learning algorithm. Clin Chim Acta 2023; 539:198-205. [PMID: 36549640 DOI: 10.1016/j.cca.2022.12.018] [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: 09/28/2022] [Revised: 12/16/2022] [Accepted: 12/17/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIMS Calcium plays a fundamental role in biological processes. Ionized calcium (Ca2+), is the biologically active fraction, but in practice total or corrected calcium assays are routinely used to determine calcium status. MATERIALS AND METHODS We retrospectively compared total and corrected calcium to assess the calcium status, with ionized calcium which is considered for now like the best indicator. To compensate for their lack of performance we created a machine learning algorithm to predict calcium status. RESULTS Corrected calcium performed less well than total calcium with 58% and 74% agreement, respectively, in our population. Total calcium was especially good for hypocalcemic samples: 93% agreement versus 45% for normocalcemic and 54% for hypercalcemic samples. Corrected calcium was especially good for hypercalcemic and normocalcemic samples: 90% and 84% agreement respectively versus 40% for hypocalcemic samples. Corrected calcium is mainly faulty in hypoalbuminemia, acid-base disorders, renal insufficiency, hyperphosphatemia, or inflammatory syndrome. With our ML algorithm, we obtained 81% correct classifications. Its main advantage is that its performance are not influenced by the variables studied or the calcium status. CONCLUSION In many situations, corrected calcium should not be used. Our ML algorithm may make a better assessment of calcium status than total calcium. Finally, if doubt, an ionized calcium assay should be performed.
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Affiliation(s)
- Candice Bancal
- Laboratoire de biochimie et biologie moléculaire, CHU Nîmes, France.
| | - Florian Salipante
- Laboratoire de biostatistique, épidémiologie clinique, santé publique, innovation et méthodologie, CHU de Nîmes, Université de Montpellier, Nîmes, France
| | - Nassim Hannas
- Laboratoire Labosud, groupe Inovie, Montpellier, France
| | - Serge Lumbroso
- Laboratoire de biochimie et biologie moléculaire, CHU Nîmes, France
| | - Etienne Cavalier
- Department of Clinical Chemistry, University of Liege, CHU de Liege, Belgium
| | - David-Paul De Brauwere
- Service de biochimie et biologie moléculaire, UM Pathologies Héréditaires du Métabolisme et Du Globule Rouge, Hospices civils de Lyon, France
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Conrich-Wilks G, Ivison F, Kilpatrick ES. Factors influencing the derivation and clinical application of blood calcium adjustment equations. Ann Clin Biochem 2023; 60:54-62. [PMID: 36154292 PMCID: PMC9853561 DOI: 10.1177/00045632221131673] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Laboratories are recommended to use patient data to derive their local adjusted calcium (adjCa) equation, using numerous criteria to exclude patients with potential calcium metabolism abnormalities. It is not known which, if any, of the exclusions influence the final equation formula, or to what extent. This study investigated the effect using fewer exclusions has on adjCa equations and on patient results when compared to a reference equation. METHODS A reference ACB adjCa equation was derived from the total calcium and albumin pairs of 1305 individuals who, from an initial 22,906 adults, met recommended criteria (excluding abnormalities in either calcium, albumin, creatinine, magnesium, ALP or ALT, and specific clinical areas). This reference equation was compared to seven alternatives derived using fewer criteria, including one with no exclusions. All equations were applied to a validation cohort (n=19,640) to determine their effect on adjCa results and on categorizing patients into hypo-, normo- or hypercalcaemia. RESULTS Most alternative adjCa equations, including the one without any exclusions, showed no statistical (p < 0.05) difference in their slope or intercept compared to the ACB reference. Nor did any of the validation cohort have a clinically significantly different adjCa result (>5% and >0.1 mmol/L different) when applying an alternative rather than the reference equation. Additionally, no alternative equation changed the kappa categorization of the validation population's calcium status. CONCLUSIONS When deriving adjCa equations, most exclusion criteria have little influence on the equation or patient results, including using none at all. This knowledge could simplify deployment of local equations.
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Affiliation(s)
- Georgia Conrich-Wilks
- Department of Medical Sciences, University of Manchester, Manchester, UK,Georgia Conrich-Wilks, Department of Clinical Biochemistry, Glasgow Royal Infirmary, Glasgow, G4 9AD, UK.
| | - Fiona Ivison
- Department of Clinical Biochemistry, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Eric S Kilpatrick
- Department of Clinical Biochemistry, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
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Kendrick JB, Zhou M, Ficociello LH, Parameswaran V, Mullon C, Anger MS, Coyne DW. Serum Phosphorus and Pill Burden Among Hemodialysis Patients Prescribed Sucroferric Oxyhydroxide: One-Year Follow-Up on a Contemporary Cohort. Int J Nephrol Renovasc Dis 2022; 15:139-149. [PMID: 35431567 PMCID: PMC9012313 DOI: 10.2147/ijnrd.s353213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 03/19/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose In prior analyses of real-world cohorts of hemodialysis patients switched from one phosphate binder (PB) to sucroferric oxyhydroxide (SO), SO therapy has been associated with improvements in serum phosphorus (sP) and reductions in daily PB pill burden. To characterize how SO initiation patterns have changed over time, we examined the long-term effectiveness of SO in a contemporary (2018–2019) cohort. Patients and Methods Adult Fresenius Kidney Care hemodialysis patients first prescribed SO monotherapy as part of routine care between May 2018 and May 2019 (N = 1792) were followed for 1 year. All patients received a non-SO PB during a 91-day baseline period before SO prescription. Mean PB pills/day and laboratory parameters were compared before and during SO treatment. Results were divided into consecutive 91-day intervals (Q1–Q4) and analyzed using linear mixed-effects regression and Cochran’s Q test. These results were contrasted with findings from a historical (2014–2015) cohort (N = 530). Results The proportion of patients achieving sP ≤5.5 mg/dl increased after switching to SO (from 27.0% at baseline to 37.8%, 45.1%, 44.7%, and 44.0% at Q1, Q2, Q3, and Q4, respectively; P < 0.0001 for all). The mean daily PB pill burden decreased from a baseline of 7.7 to 4.4, 4.6, 4.8, and 4.9, respectively, across quarters (P < 0.0001 for all). Patients in the contemporary cohort had improved sP control (27.0% achieving sP ≤5.5 mg/dl vs 17.7%) and lower daily PB pill burden (mean 7.7 vs 8.5 pills/day) at baseline than those in the historical cohort. Overall use of active vitamin D was similar between cohorts, although higher use of oral active vitamin D (63.9% vs 15.7%) and lower use of IV active vitamin D lower (23.4% vs 74.2%) was observed in the contemporary cohort. Conclusion Despite evolving treatment patterns, switching to SO resulted in improved sP control with fewer pills per day in this contemporary hemodialysis cohort.
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Affiliation(s)
| | - Meijiao Zhou
- Fresenius Medical Care Global Medical Office, Waltham, MA, USA
| | | | | | - Claudy Mullon
- Fresenius Medical Care Global Medical Office, Waltham, MA, USA
| | - Michael S Anger
- Fresenius Medical Care Global Medical Office, Waltham, MA, USA
- Unversity of Colorado School of Medicine, Denver, CO, USA
| | - Daniel W Coyne
- Washington University School of Medicine, St. Louis, MO, USA
- Correspondence: Daniel W Coyne, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA, Tel +1 314-362-7603, Fax +1 314-747-5213, Email
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Ramirez-Sandoval JC, Diener-Cabieses P, Gutiérrez-Valle F, Ley-Tapia S, Pastrana-Brandes S, Galindo PE, Fagundo R, Moreno-Yañez M, Reza-Albarrán AA, Correa-Rotter R. Validation of an equation for free calcium estimation: accuracy improves after adjustment for phosphate and CO 2. Int Urol Nephrol 2022; 54:2625-2635. [PMID: 35294676 DOI: 10.1007/s11255-022-03170-z] [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: 07/26/2021] [Accepted: 02/27/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Free calcium is the gold standard for diagnosis of calcium disorders, although calcium assessment is routinely performed by albumin-adjusted calcium. Our objective was to develop a novel-specific correction equation for free calcium employing serum total calcium and other analytes. METHODS Retrospective single-center cohort study. A new equation for free calcium assessment was formulated from data of hospitalized patients (n = 3481, measurements = 7157) and tested in a validation cohort (n = 3218, measurements = 6911). All measurements were performed simultaneously from the same blood draw. RESULTS Total CO2 and phosphate, in addition to albumin, were the principal factors associated to calcium misdiagnosis. A novel laboratory-specific prediction equation was developed: free calcium (mmol/L) = 0.541 + (total calcium [mmol/L] *0.441) - (serum albumin [g/L] *0.0067) - (serum phosphate [mmol/L] *0.0425) - (CO2 [mmol/L] *0.003). This new equation substantially improved adjusted R2 to 0.67 (95% CI 0.78-0.82, p < 0.001; Kendall's c-tau: 0.28, p < 0.001). Bland-Altman plots of estimated free calcium and free calcium showed a mean difference of - 0.0006 mmol/L (LOA + 0.126 to - 0.124). In validation cohort, the AUC-ROC curves for hypercalcemia and hypocalcemia diagnosis deploying the new equation were 0.88 (95% CI 0.86-0.89, p < 0.001) and 0.98 (95% CI 0.97-99, p < 0.001), respectively, which were superior to historical formulas for calcium. In univariate models, eGFR was associated with Ca-status misdiagnosis, yet this association disappeared when analysis was adjusted to phosphate and CO2. CONCLUSIONS The novel equation proposed for prediction of free calcium could be useful when free calcium is not available. The conventional formulas misclassify many patients, in particular when phosphate or bicarbonate disturbances are present.
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Affiliation(s)
- Juan C Ramirez-Sandoval
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Dominguez Sección XVI, 14080, Mexico City, Mexico.
| | | | | | - Sofía Ley-Tapia
- Escuela de Medicina, Universidad Panamericana, Mexico City, Mexico
| | | | - Pablo E Galindo
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Dominguez Sección XVI, 14080, Mexico City, Mexico
| | - Reynerio Fagundo
- Central Laboratory, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Mauricio Moreno-Yañez
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Dominguez Sección XVI, 14080, Mexico City, Mexico
| | - Alfredo Adolfo Reza-Albarrán
- Department of Endocrinology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ricardo Correa-Rotter
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Dominguez Sección XVI, 14080, Mexico City, Mexico
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8
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Law MM, Smith JD, Schneider HG, Wilson S. Misclassification of calcium status in end-stage kidney disease using albumin-adjusted calcium levels. Nephrology (Carlton) 2021; 26:725-732. [PMID: 34089212 DOI: 10.1111/nep.13910] [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] [Received: 02/23/2021] [Revised: 05/16/2021] [Accepted: 05/24/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Albumin-adjusted calcium remains widely used in clinical practice with guidelines for chronic kidney disease (CKD) mineral bone disorder recommending the use of serum calcium for monitoring. This is despite ionized calcium being the biologically active fraction. This study aimed to investigate the ability of total calcium and albumin-adjusted calcium to correctly assign calcium status in stage 5/5D CKD across non-dialysis, haemodialysis and peritoneal dialysis patients. METHODS Over a 6-months, 352 paired serum and ionized calcium samples were collected from stage 5 (n = 58) and 5D (n = 294, 196 haemodialysis, 98 peritoneal dialysis) CKD patients in a tertiary-hospital setting. Albumin-adjusted calcium was calculated using the modified-Payne formula. Ionized calcium was the reference standard. The agreement between the two methods in assigning calcium status was assessed using Cohen's weighted kappa (κ) statistic. RESULTS Albumin-adjusted calcium was a poor predictor of calcium status compared to ionized calcium in stage 5/5D CKD (observed agreement 0.42, weighted κ 0.20, 95% CI 0.15-0.26). Dialysis dependence was associated with worse agreement (observed agreement 0.38, weighted κ 0.14, 95% CI 0.09-0.19). Total calcium was more reliable, however, remained inaccurate. Calcium status was not more accurately classified in those with higher albumin levels ≥30 g/L (observed agreement 0.47, weighted κ 0.23, 95% CI 0.10-0.36). CONCLUSION Total calcium provides better approximation of calcium status than albumin-adjusted calcium in stage 5/5D CKD. Albumin-adjusted calcium tends to 'overcorrect' serum calcium upward. Clinicians should use ionized calcium where accurate measure of calcium is indicated, with total calcium used as the next best option where resources are limited.
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Affiliation(s)
- Mandy M Law
- Department of Renal Medicine, Alfred Health, Melbourne, Victoria, Australia.,Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Joel D Smith
- Department of Pathology, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Laboratory Services, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Hans G Schneider
- Clinical Biochemistry Unit, The Alfred Pathology Service, Alfred Health, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
| | - Scott Wilson
- Department of Renal Medicine, Alfred Health, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
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9
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Yap E, Roche-Recinos A, Goldwasser P. Predicting Ionized Hypocalcemia in Critical Care: An Improved Method Based on the Anion Gap. J Appl Lab Med 2021; 5:4-14. [PMID: 32445343 DOI: 10.1373/jalm.2019.029314] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 04/30/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Low ionized calcium (ICa) is prevalent in critical care patients. It is poorly detected by the popular indirect method, which corrects serum total calcium (TCa) for change in albumin. That correction (cTCa) ignores any concomitant change in the anion-complexed fraction of TCa. We tested whether the diagnosis of low ICa can be improved by further correcting for calcium complexation, represented by the anion gap (AG) or its components-sodium, chloride, and total carbon dioxide (tCO2). METHODS We retrospectively studied all patients in our intensive care units between 2009 and 2011 with ICa measured on arterial (n = 310) or venous (n = 462) gas panels within 19 min of a comprehensive chemistry panel. Logistic models to predict low ICa and linear models to estimate ICa were derived in the arterial group and validated in the venous group, using either AG (AG model) or its components (Ion model) as predictors, adjusted for TCa and albumin. RESULTS AG and its set of components were each highly significant independent predictors of low ICa. On validation, the logistic Ion model was better than the logistic AG model (ROC curve area ± SE: 0.92 ± 0.02 vs 0.89 ± 0.02; P = 0.008), which, in turn, was far better than cTCa (0.81 ± 0.03; P = 0.0006); the hypocalcemia rates predicted by the models showed good fit with the observed rates. Linear estimates of ICa were too imprecise for clinical use. CONCLUSIONS The adjustment of TCa for AG or for sodium, chloride, and tCO2 markedly improves the diagnosis of low ICa. This finding may be useful in guiding ICa testing.
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Affiliation(s)
- Ernie Yap
- State University of New York, Downstate Medical Center, Brooklyn, NY
| | | | - Philip Goldwasser
- Department of Medicine, Veterans Affairs New York Harbor Healthcare System, Brooklyn, NY
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Zhu J, Tang C, Ouyang H, Shen H, You T, Hu J. Prediction of All-Cause Mortality Using an Echocardiography-Based Risk Score in Hemodialysis Patients. Cardiorenal Med 2020; 11:33-43. [PMID: 33333520 DOI: 10.1159/000507727] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 03/31/2020] [Indexed: 11/19/2022] Open
Abstract
AIM To derive an echocardiography-based prognostic score for a 3-year risk of mortality in end-stage renal disease (ESRD) patients undergoing hemodialysis (HD). METHODS 173 ESRD patients hospitalized in the second affiliated hospital of Soochow University from January 1, 2010, to July 31, 2016, were enrolled and followed up for 3 years. All subjects began to receive HD from recruitment. Baseline clinical and echocardiographic parameters were collected and screened for risk factors using univariate and multivariate analysis. The prognostic value of echocardiographic indexes was determined by concordance indexes and reclassification assay. Restricted cubic spline models (RCS) and forest plots were employed to visualize the association between risk factors and all-cause mortality. A multivariate nomogram including the identified factors was developed to estimate the prognosis. RESULTS After multivariate adjustment for advanced age, hypertension, diabetes, and decreased hemoglobin (Hb), echocardiographic indexes including left atrial diameter index (LADI), cardiac valvular calcification, and moderate to severe cardiac valve regurgitation were independently associated with the risk of 3-year mortality in HD patients. RCS showed that age, Hb, and LADI were positively associated with the risk of mortality. Adding multiple echocardiographic indexes to a basic model containing age, hypertension, diabetes, and Hb increased the concordance index and improved reclassification. A multivariate Cox model-derived nomogram showed the association between each factor and mortality by the end of follow-up. CONCLUSIONS Echocardiographic indexes showed independent predictive power for mortality in ESRD patients and may constitute a promising prognostic tool in this population.
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Affiliation(s)
- Jing Zhu
- The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Chao Tang
- The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Han Ouyang
- The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Huaying Shen
- The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Tao You
- The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Ji Hu
- The Second Affiliated Hospital of Soochow University, Suzhou, China,
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Holden RM, Mustafa RA, Alexander RT, Battistella M, Bevilacqua MU, Knoll G, Mac-Way F, Reslerova M, Wald R, Acott PD, Feltmate P, Grill A, Jindal KK, Karsanji M, Kiberd BA, Mahdavi S, McCarron K, Molnar AO, Pinsk M, Rodd C, Soroka SD, Vinson AJ, Zimmerman D, Clase CM. Canadian Society of Nephrology Commentary on the Kidney Disease Improving Global Outcomes 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder. Can J Kidney Health Dis 2020; 7:2054358120944271. [PMID: 32821415 PMCID: PMC7412914 DOI: 10.1177/2054358120944271] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 06/06/2020] [Indexed: 12/23/2022] Open
Abstract
Purpose of review: (1) To provide commentary on the 2017 update to the Kidney Disease Improving Global Outcomes (KDIGO) 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD); (2) to apply the evidence-based guideline update for implementation within the Canadian health care system; (3) to provide comment on the care of children with chronic kidney disease (CKD); and (4) to identify research priorities for Canadian patients. Sources of information: The KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of CKD-MBD. Methods: The commentary committee co-chairs selected potential members based on their knowledge of the Canadian kidney community, aiming for wide representation from relevant disciplines, academic and community centers, and different geographical regions. Key findings: We agreed with many of the recommendations in the clinical practice guideline on the diagnosis, evaluation, prevention, and treatment of CKD-MBD. However, based on the uncommon occurrence of abnormalities in calcium and phosphate and the low likelihood of severe abnormalities in parathyroid hormone (PTH), we recommend against screening and monitoring levels of calcium, phosphate, PTH, and alkaline phosphatase in adults with CKD G3. We suggest and recommend monitoring these parameters in adults with CKD G4 and G5, respectively. In children, we agree that monitoring for CKD-MBD should begin in CKD G2, but we suggest measuring ionized calcium, rather than total calcium or calcium adjusted for albumin. With regard to vitamin D, we suggest against routine screening for vitamin D deficiency in adults with CKD G3-G5 and G1T-G5T and suggest following population health recommendations for adequate vitamin D intake. We recommend that the measurement and management of bone mineral density (BMD) be according to general population guidelines in CKD G3 and G3T, but we suggest against routine BMD testing in CKD G4-G5, CKD G4T-5T, and in children with CKD. Based on insufficient data, we also recommend against routine bone biopsy in clinical practice for adults with CKD or CKD-T, or in children with CKD, although we consider it an important research tool. Limitations: The committee relied on the evidence summaries produced by KDIGO. The CSN committee did not replicate or update the systematic reviews.
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Affiliation(s)
- Rachel M Holden
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Reem A Mustafa
- Division of Nephrology and Hypertension, Department of Internal Medicine, The University of Kansas Medical Center, Kansas City, USA.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - R Todd Alexander
- Department of Pediatrics and Physiology, University of Alberta, Edmonton, Canada
| | - Marisa Battistella
- University Health Network, Leslie Dan Faculty of Pharmacy, University of Toronto, ON, Canada
| | - Micheli U Bevilacqua
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Greg Knoll
- Division of Nephrology, The Ottawa Hospital, ON, Canada
| | - Fabrice Mac-Way
- Division of Nephrology, CHU de Québec, Hôtel-Dieu de Québec Hospital, Université Laval, Québec City, QC, Canada
| | - Martina Reslerova
- Nephrology Section, St. Boniface General Hospital, University of Manitoba, Winnipeg, Canada
| | - Ron Wald
- Division of Nephrology, St. Michael's Hospital, University of Toronto, ON, Canada
| | - Philip D Acott
- Division of Nephrology, Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | - Patrick Feltmate
- Department of Geriatric Medicine, Dalhousie University, Halifax, NS, Canada
| | - Allan Grill
- Department of Family & Community Medicine, University of Toronto, ON, Canada
| | - Kailash K Jindal
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Meena Karsanji
- Professional Practice, Vancouver Coastal Health, Richmond, BC, Canada
| | - Bryce A Kiberd
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Sara Mahdavi
- Department of Nutritional Sciences, University of Toronto, ON, Canada.,Department of Nephrology, Scarborough Health Network, ON, Canada
| | - Kailee McCarron
- Nova Scotia Renal Program, Nova Scotia Health Authority, Halifax, Canada
| | - Amber O Molnar
- Division of Nephrology, McMaster University, Hamilton, ON, Canada
| | - Maury Pinsk
- Division of Nephrology, Department of Pediatrics & Child Health, University of Manitoba, Winnipeg, Canada
| | - Celia Rodd
- Division of Diabetes & Endocrinology, Department of Pediatrics & Child Health, University of Manitoba, Winnipeg, Canada
| | - Steven D Soroka
- Division of Nephrology, Department of Medicine, Dalhousie University, NSHA Renal Program and Pharmacy Services, Halifax, NS, Canada
| | - Amanda J Vinson
- Division of Nephrology, Dalhousie University, Halifax, NS, Canada
| | - Deborah Zimmerman
- Division of Nephrology, Department of Medicine, University of Ottawa, ON, Canada
| | - Catherine M Clase
- Division of Nephrology, Department of Medicine, Department of Health Research, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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Toffaletti JG. Predicting Ionized Hypocalcemia with Total Calcium: Can "Correction" with Logistical Modeling of Multiple Analytes Do the Trick? J Appl Lab Med 2020; 5:1-3. [PMID: 32445336 DOI: 10.1373/jalm.2019.030197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 07/01/2019] [Indexed: 01/13/2023]
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13
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Kur DK, Hillig T, Hansen SI, Goharian T, Witte ML, Thode J. Evaluation of a New Automated Routine Measurement for Serum Adjusted Ionized Calcium (at pH 7.4) in Patients Suspected of Calcium Metabolic Disease. J Appl Lab Med 2020; 5:704-715. [DOI: 10.1093/jalm/jfaa006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 11/01/2019] [Indexed: 11/14/2022]
Abstract
AbstractBackgroundTotal calcium is a less accurate test in predicting ionized calcium (Ca2+) in patients suspected of calcium metabolic disease. Nevertheless, total calcium continues to be used as routine measurement instead of adjusted Ca2+ (at pH 7.4). In the current study we evaluate a new multichannel instrument, the ISE Module E1200 for adjusted Ca2+ (at pH 7.4), containing three different ion-selective electrode (ISE) units.MethodsSerum from 1350 patients was compared to the ABL835 flex and KoneLab. Total calcium was also evaluated on the Dimension Vista 1500 system. Correlations between instruments were assessed by Deming regression and degree of agreement by Cohen’s kappa (κ).ResultsAnalytical imprecisions for the three ISE units for adjusted Ca2+ (at pH 7.4) was between 0.36% and 2.52%, and for pH between 0.32% and 3.24%. Results were comparable for each ISE unit (r = 0.797–0.917; all P < 0.0001) and in high-throughput settings (r = 0.871; P < 0.0001). The degree of agreement between instruments was moderate to good (κ = 0.52–0.77). In contrast, there was a very poor agreement (κ = −0.14) for total calcium with discrepancy in 53.4% of the samples.ConclusionsThe new ISE Module E1200 is comparable with the ABL835 flex and KoneLab 30i and therefore may be used for routine analysis of serum adjusted Ca2+ (at pH 7.4). The measured adjusted Ca2+ (at pH 7.4) was less comparable with very poor agreement to total calcium measured on the Dimension Vista 1500 system.
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Affiliation(s)
| | - Thore Hillig
- Department of Clinical Biochemistry, North Zealand Hospital Hilleroed, University of Copenhagen, Copenhagen, Denmark
| | - Steen I Hansen
- Department of Clinical Biochemistry, North Zealand Hospital Hilleroed, University of Copenhagen, Copenhagen, Denmark
| | - Tina Goharian
- Department of Clinical Biochemistry, North Zealand Hospital Hilleroed, University of Copenhagen, Copenhagen, Denmark
| | - Majbritt L Witte
- Department of Clinical Biochemistry, North Zealand Hospital Hilleroed, University of Copenhagen, Copenhagen, Denmark
| | - Jorgen Thode
- Department of Clinical Biochemistry, North Zealand Hospital Hilleroed, University of Copenhagen, Copenhagen, Denmark
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14
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Hidden Hypocalcemia as a Risk Factor for Cardiovascular Events and All-Cause Mortality among Patients Undergoing Incident Hemodialysis. Sci Rep 2020; 10:4418. [PMID: 32157180 PMCID: PMC7064591 DOI: 10.1038/s41598-020-61459-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 02/26/2020] [Indexed: 12/16/2022] Open
Abstract
Lower corrected calcium (cCa) levels are associated with a better prognosis among incident dialysis patients. However, cCa frequently overestimates ionized calcium (iCa) levels. The prognostic importance of the true calcium status defined by iCa remains to be revealed. We conducted a retrospective cohort study of incident hemodialysis patients. We collected data of iCa levels immediately before the first dialysis. We divided patients into three categories: apparent hypocalcemia (low iCa; <1.15 mmol/L and low cCa; <8.4 mg/dL), hidden hypocalcemia (low iCa despite normal or high cCa), and normocalcemia (normal iCa). The primary outcome was the composite of all-cause death and cardiovascular diseases after hospital discharge. Among the enrolled 332 patients, 75% of the patients showed true hypocalcemia, defined as iCa <1.15 mmol/L, 61% of whom showed hidden hypocalcemia. In multivariate Cox models including other potential risk factors, true hypocalcemia was a significant risk factor (hazard ratio [HR], 2.34; 95% confidence interval [CI], 1.03–5.34), whereas hypocalcemia defined as corrected calcium <8.4 mg/dL was not. Furthermore, hidden hypocalcemia was significantly associated with an increased risk of the outcome compared with normocalcemia (HR, 2.56; 95% CI, 1.11–5.94), while apparent hypocalcemia was not. Patients with hidden hypocalcemia were less likely to receive interventions to correct hypocalcemia, such as increased doses of active vitamin D or administration of calcium carbonate, than patients with apparent hypocalcemia (odds ratio, 0.45; 95% CI, 0.23–0.89). Hidden hypocalcemia was a strong predictor of death and cardiovascular events, suggesting the importance of measuring iCa.
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Abstract
BackgroundWe previously reported a very high incidence of calciphylaxis, mainly in peritoneal dialysis (PD) patients. Although we identified several risk factors for the condition, including PD, we were unable to identify why our particular unit had such a high frequency of the condition and a reliable treatment.ObjectivesTo assess the apparent changing frequency of the condition and the response to therapy, and to attempt to determine putative factors that might explain our uniquely high incidence of calciphylaxis.MethodsA prospective clinical record was kept on all patients that developed calciphylaxis in our center [both PD and hemodialysis (HD) units] between 1998 and 2006.ResultsOf the 59 patients that developed calciphylaxis, 54 were on PD, 4 were on HD, and 1 was in predialysis. In the PD population, the mean yearly incidence from 1998 to 2003 was 4.5/100 patient-years, falling to 1.3/100 patient-years in 2004 – 2006. The percent of patients not taking calcium salts fell during this time period. Conversion to HD led to marked early improvement. A marked discrepancy between the levels of ionized calcium (routinely used in our center) and corrected serum calcium was found, with most cases of hypercalcemia (corrected) being missed by using ionized values.ConclusionsThe incidence of calciphylaxis is falling dramatically. This may be related partially to reduction in usage of calcium salts. Conversion to HD is beneficial. Our uniquely high incidence of calciphylaxis may be related to our use of ionized calcium levels to monitor these patients.
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Affiliation(s)
- Adrian Fine
- Section of Nephrology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Bunny Fontaine
- Section of Nephrology, University of Manitoba, Winnipeg, Manitoba, Canada
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16
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Pekar JD, Grzych G, Durand G, Haas J, Lionet A, Brousseau T, Glowacki F, Maboudou P. Calcium state estimation by total calcium: the evidence to end the never-ending story. Clin Chem Lab Med 2020; 58:222-231. [PMID: 31473684 DOI: 10.1515/cclm-2019-0568] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 08/07/2019] [Indexed: 01/31/2023]
Abstract
Background Total blood calcium (TCa) is routinely used to diagnose and manage mineral and bone metabolism disorders. Numerous laboratories adjust TCa by albumin, though literature suggests there are some limits to this approach. Here we report a large retrospective study on agreement rate between ionized calcium (iCa) measurement and TCa or albumin-adjusted calcium measurements. Methods We retrospectively selected 5055 samples with simultaneous measurements of iCa, TCa, albumin and pH. We subgrouped our patients according to their estimated glomerular filtration rate (eGFR), albumin levels and pH. We analyzed each patient's calcium state with iCa as reference to determine agreement rate with TCa and albumin-adjusted calcium using Payne, Clase, Jain and Ridefelt formulas. Results The Payne formula performed poorly in patients with abnormal albumin, eGFR or pH levels. In patients with low albumin levels or blood pH disorders, Payne-adjusted calcium may overestimate the calcium state in up to 80% of cases. Similarly, TCa has better agreement with iCa in the case of hypoalbuminemia, but performed similarly to the Payne formula in patients with physiological albumin levels. The global agreement rate for Clase, Jain and Ridefelt formulas suggests significant improvement compared to Payne calcium adjustment but no significant improvement compared to TCa. Conclusions Total and albumin-adjusted calcium measurement leads to a misclassification of calcium status. Moreover, accurate calcium state determination depends on blood pH levels, whose measurement requires the same pre-analytical restrictions as iCa measurement. We propose that iCa should instead become the reference method to determine the real calcium state.
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Affiliation(s)
| | - Guillaume Grzych
- Centre de Biologie Pathologie, Laboratoire d'Hormonologie, Métabolisme-Nutrition, Oncologie, rue du Pr J. Leclercq, CHU Lille, F-59000 Lille, France.,Université de Lille, INSERM UMR-1011, Lille, France
| | - Gatien Durand
- CHU Lille, UF 8832 Biochimie automatisée, Lille, France
| | - Joël Haas
- Université de Lille, INSERM UMR-1011, Lille, France
| | - Arnaud Lionet
- CHU Lille, Service de Néphrologie et Transplantation, Lille, France
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Louie KS, Erhard C, Wheeler DC, Stenvinkel P, Fouqueray B, Floege J. Cinacalcet-induced hypocalcemia in a cohort of European haemodialysis patients: predictors, therapeutic approaches and outcomes. J Nephrol 2019; 33:803-816. [PMID: 31848883 PMCID: PMC7381480 DOI: 10.1007/s40620-019-00686-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 12/08/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Calcimimetic treatment of secondary hyperparathyroidism in chronic dialysis patients is often followed by hypocalcemia. METHODS We investigated the frequency, predictors, consequences and therapeutic responses following cinacalcet-induced hypocalcemia in an incident European hemodialysis cohort of 1068 patients with a cinacalcet prescription. RESULTS Of 905 normocalcemic patients initiating cinacalcet, 67% developed hypocalcemia within 12 months: 68% mild, 23% moderate, 9% severe. Compared to persistently normocalcemic patients, those with severe hypocalcemia were more often diabetic, overweight, had cardiovascular disease, shorter dialysis vintage, used a catheter dialysis access, had fewer active vitamin-D sterols, and exhibited higher CRP and iPTH and lower calcium levels. Multivariate predictors of hypocalcemia included a catheter for vascular access, low albumin and high iPTH. Generally, no therapeutic intervention to prevent hypocalcemia was taken prior to cinacalcet initiation. After the hypocalcemic event, the most common clinical response was no change of the dialysis or medical regimen. Following the hypocalcemic event, iPTH remained low even in those with severe hypocalcemia. The number of deaths and cardiovascular events did not differ between patients with and without hypocalcemia within six months following cinacalcet initiation. CONCLUSION Two-thirds of cinacalcet initiated patients experienced hypocalcaemia with 9% being severe. Hypocalcemia was mostly asymptomatic, transient (with and without targeted intervention to correct it) and not associated with an increase in cardiovascular events or deaths.
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Affiliation(s)
| | | | - David C Wheeler
- Department of Nephrology, University College London, London UK and George Institute for Global Health, Sydney, Australia
| | - Peter Stenvinkel
- Division of Renal Medicine, Department of Clinical Science Technology and Intervention, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | | | - Jürgen Floege
- Division of Nephrology & Clinical Immunology, RWTH University of Aachen, Pauwelsstraẞe 30, 52057, Aachen, Germany.
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DOĞAN Ö. Hipokalsemi Olan Hastalarda Serum Kalsiyum Düzeylerinin İyonize ve Düzeltilmiş Kalsiyum ile İlişkisi. DÜZCE ÜNIVERSITESI SAĞLIK BILIMLERI ENSTITÜSÜ DERGISI 2019. [DOI: 10.33631/duzcesbed.547378] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Kendrick J, Parameswaran V, Ficociello LH, Ofsthun NJ, Davis S, Mullon C, Kossmann RJ, Kalantar-Zadeh K. One-Year Historical Cohort Study of the Phosphate Binder Sucroferric Oxyhydroxide in Patients on Maintenance Hemodialysis. J Ren Nutr 2019; 29:428-437. [PMID: 30679076 PMCID: PMC6642852 DOI: 10.1053/j.jrn.2018.11.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 11/11/2018] [Accepted: 11/20/2018] [Indexed: 12/16/2022] Open
Abstract
Objective: The high pill burden of many phosphate binders (PBs) may contribute to increased prevalence of hyperphosphatemia and poor nutritional status observed among patients undergoing maintenance hemodialysis therapy. We examined the real-world effectiveness of sucroferric oxyhydroxide (SO), a PB with low pill burden, in managing serum phosphorus in patients with prevalent hemodialysis over a 1-year period. Design: Historical cohort analyses of de-identified electronic medical records. Subjects: In-center hemodialysis patients switched from another PB to SO therapy as part of routine care with 12 months of uninterrupted SO prescriptions recorded, and documented serum phosphorus levels were eligible for inclusion. Clinical data were extracted from a pharmacy service, FreseniusRx, database and Fresenius Kidney Care clinical data warehouse. Main outcome measures: Comparisons were made between the 91-day period before SO initiation (i.e., baseline) and the 4 consecutive 91-day intervals of SO treatment (Q1-Q4). Clinical measures included achievement of target phosphorus levels (#5.5 mg/dL) and mean number of PB pills/day. Results: Among 530 analyzed patients, the proportion achieving target serum phosphorus levels increased by >100% 1 year after switching to SO therapy, that is, from 17.7% at baseline to 24.5%, 30.5%, 36.4%, and 36.0% at Q1 through Q4, respectively (P < .0001 for all). Reductions in serum phosphorus were observed at all follow-up timepoints (P <.0001), irrespective of baseline PB. From a mean baseline PB pill burden of 8.5 pills/day, patients experienced an average 50% pill burden reduction during SO treatment (P <. 0001). Phosphorus-attuned albumin and phosphorus-attuned protein intake (normalized protein catabolic rate) improved significantly after transition to SO (P < .0001). The effectiveness of SO was evident in prespecified subgroups of interest (i.e., black/African-American patients, Hispanic/Latino patients, and women). Conclusion: Among patients on hemodialysis, switching to SO resulted in a 2-fold greater likelihood of achieving target phosphorus levels while halving daily PB pill burden. Increases in phosphorus-attuned albumin and protein intake suggest improved nutritional status.
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Affiliation(s)
- Jessica Kendrick
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Medicine, Denver Health Medical Center, Denver, Colorado
| | | | | | - Norma J Ofsthun
- Fresenius Medical Care North America, Waltham, Massachusetts
| | - Shannon Davis
- Fresenius Medical Care North America, Waltham, Massachusetts
| | - Claudy Mullon
- Fresenius Medical Care Renal Therapies Group, Waltham, Massachusetts
| | - Robert J Kossmann
- Fresenius Medical Care Renal Therapies Group, Waltham, Massachusetts
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21
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Smith JD, Wilson S, Schneider HG. Misclassification of Calcium Status Based on Albumin-Adjusted Calcium: Studies in a Tertiary Hospital Setting. Clin Chem 2018; 64:1713-1722. [DOI: 10.1373/clinchem.2018.291377] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 08/23/2018] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
Clinical laboratories measure total calcium and adjust for albumin concentrations to predict calcium status. We compared total and adjusted calcium (Adj-Ca) with ionized calcium (Ca2+) for correct assignment of calcium status. The effect of restriction of Adj-Ca reporting in patients with hypoalbuminemia was determined on the basis of frequency of misclassifications.
METHODS
Extraction of laboratory results was performed for 24 months. Adj-Ca was calculated from a modified Payne formula. A further prospective data set for 6 months was collected after stopping reporting of Adj-Ca for patients with an albumin <3.0 g/dL. The agreement between Ca2+ and Adj-Ca or total Ca was assessed with Cohen's kappa statistic.
RESULTS
In 5553 hospitalized patients, 13604 paired Ca2+ results were analyzed retrospectively. Prospective collection in 1113 paired samples was from 450 patients. Adj-Ca was a poor predictor of calcium status compared to the Ca2+ reference standard in both data sets (agreement 56.9% in the first, 65.6% in the second data set). Renal failure and low albumin concentrations were associated with worse agreement between Adj-Ca and Ca2+. Restriction of reporting of Adj-Ca to albumin concentrations >3.0g/dL improved correct classification of calcium status from 65.6% to 77.6% (P < 0.0001). Total Ca performed better than Adj-Ca for low albumin (<3.0g/dL) and performed similarly in samples with albumin >3.0g/dL.
CONCLUSIONS
Adj-Ca is unreliable for the classification of calcium status in hospital patients when compared to Ca2+. Adj-Ca overestimates calcium for patients with renal impairment and albumin concentrations <3.0g/dL. Restriction of reporting Adj-Ca for albumin below 3.0 g/dL reduces the number of misclassified patients.
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Affiliation(s)
- Joel D Smith
- Clinical Biochemistry Unit, Alfred Pathology Service, Alfred Health, Melbourne, Australia
| | - Scott Wilson
- Department of Renal Medicine, Alfred Health, Melbourne, Australia
- Monash University, Melbourne, Victoria, Australia
| | - Hans G Schneider
- Clinical Biochemistry Unit, Alfred Pathology Service, Alfred Health, Melbourne, Australia
- Monash University, Melbourne, Victoria, Australia
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22
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de Roij van Zuijdewijn CL, de Haseth DE, van Dam B, Bax WA, Grooteman MP, Bots ML, Blankestijn PJ, Nubé MJ, van den Dorpel MA, ter Wee PM, Penne EL. Role of Albumin Assay on Calcium Levels and Prescription of Phosphate Binders in Chronic Hemodialysis Patients. Nephron Clin Pract 2018; 140:211-217. [PMID: 30212837 PMCID: PMC6262677 DOI: 10.1159/000492238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 07/17/2018] [Accepted: 07/17/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS In hemodialysis (HD) patients, the bromcresol green (BCG) assay overestimates, whereas the bromcresol purple (BCP) assay underestimates albumin concentration. Since corrected calcium concentrations depend on albumin, the albumin assay may have implications for the management of bone mineral disorders. METHODS A subset of patients from CONTRAST, a cohort of prevalent HD patients, was analyzed. Bone mineral parameters and prescription of medication were compared between patients in whom albumin was assessed by BCP versus BCG. RESULTS Albumin was assessed by BCP in 331 patients (9 of 25 centers) and by BCG in 175 patients (16 of 25 centers). Albumin was the lowest in the BCP group (34.5 ± 4.2 vs. 40.3 ± 3.1 g/L; p < 0.0005). Measured calcium levels and the prescription of calcium-based phosphate binders were similar in both groups. Corrected calcium levels, however, were markedly higher in the BCP group (2.45 ± 0.18 vs. 2.33 ± 0.18 mmol/L; p < 0.0005). CONCLUSION These findings suggest that calcium levels are not corrected for albumin in clinical practice when considering the prescription of calcium-free or calcium-based phosphate-binders in dialysis patients.
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Affiliation(s)
| | - Dinky E. de Haseth
- Department of Internal Medicine, Northwest Clinics, Alkmaar, The Netherlands
| | - Bastiaan van Dam
- Department of Internal Medicine, Northwest Clinics, Alkmaar, The Netherlands
| | - Willem A. Bax
- Department of Internal Medicine, Northwest Clinics, Alkmaar, The Netherlands
| | - Muriel P.C. Grooteman
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Nephrology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Michiel L. Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, The Netherlands
| | - Peter J. Blankestijn
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Menso J. Nubé
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Nephrology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | | | - Pieter M. ter Wee
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Nephrology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Erik L. Penne
- Department of Internal Medicine, Northwest Clinics, Alkmaar, The Netherlands
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Maheshwari V, Cherif A, Fuertinger D, Schappacher-Tilp G, Preciado P, Thijssen S, Bushinsky DA, Kotanko P. An in silico method to predict net calcium transfer during hemodialysis. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2018; 2017:2740-2743. [PMID: 29060465 DOI: 10.1109/embc.2017.8037424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
International guidelines for chronic hemodialysis patients suggest a dialysate calcium concentration between 1.25 and 1.5 mmol/L. However, it is not certain if these dialysate calcium levels result in net calcium transfer into the patient. With ubiquitous prevalence of vascular calcification in hemodialysis patients, it is pertinent to model the mass balance of calcium during dialysis. To this end, we developed a two compartmental patient model and spatiotemporal representation of dialyzer model to investigate and quantify the calcium mass balance during dialysis. The model accounts for calcium-albumin binding and varying protein concentration; the latter accounts for the Gibbs-Donnan effect. The model simulations suggest that despite a lower dialysate calcium concentration of 1.25 mmol/L, some of our patients may be loaded with calcium during dialysis. This net calcium flux from dialysate to blood side may be a potential contributor to vascular calcification, a primary cause of cardiovascular mortality in hemodialysis patients.
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Abstract
PURPOSE OF REVIEW Calcium is an essential ion for the maintenance of normal bone health and physiologic functions. The extracellular and intracellular levels of calcium are maintained through hormonal regulation called homeostasis. Balance, the net intake minus excretion of calcium, is maintained by hormonal regulation of intestinal absorption and fecal/urinary excretion. Homeostasis and balance are disconnected in patients with chronic kidney disease (CKD). The purpose of this review is to understand how calcium homeostasis and balance are impaired in CKD. RECENT FINDINGS Two formal calcium balance studies have found that an oral intake of 800-1000 mg of calcium in adults with CKD leads to neutral calcium balance, whereas amounts greater than that lead to positive calcium balance. In patients with CKD, the main determinant of positive calcium balance is the intake and the lack of urinary calcium excretion. SUMMARY Calcium balance is different in patients with advanced CKD compared with patients without CKD. Thus, the oral intake of calcium in the form of diet and binders should not exceed 800-1000 mg/day to achieve neutral calcium balance in adult patients with CKD stages 3b/4.
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Affiliation(s)
- Sharon M Moe
- Division of Nephrology, Indiana University School of Medicine
- Department of Medicine, Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana, USA
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25
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Obi Y, Park C, Soohoo M, Sumida K, Hamano T, Rhee CM, Kovesdy CP, Kalantar-Zadeh K, Streja E. Association of Pre-ESRD Serum Calcium With Post-ESRD Mortality Among Incident ESRD Patients: A Cohort Study. J Bone Miner Res 2018; 33:1027-1036. [PMID: 29342320 DOI: 10.1002/jbmr.3391] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 12/12/2017] [Accepted: 01/05/2018] [Indexed: 12/12/2022]
Abstract
Albumin-corrected serum calcium (cSCa) decline at late stages of chronic kidney disease and rise after dialysis initiation. Although hypercalcemia is associated with higher mortality in end-stage renal disease (ESRD), there are scarce data on the impact of pre-ESRD cSCa on post-ESRD mortality. Therefore, we used a large national cohort of 21,826 US veterans who transitioned to dialysis in all US Department of Veterans Affairs health care facilities over 2009 to 2014 to examine the associations with all-cause and cause-specific post-ESRD mortality of (1) cSCa concentrations averaged over the last 6 months and (2) its rate of decline during the last 12 months before dialysis initiation. Mean concentrations and median rate of decline of cSCa were 9.3 ± 0.7 mg/dL and -0.15 (interquartile range -0.39 to 0.07) mg/dL/year, respectively. A total of 9596 patients died during the follow-up period (mean 1.9 years; total 41,541 patient-years) with an incidence rate of 23.1 per 100 patient-years. There was an independent linear association between higher cSCa with higher mortality (ptrend < 0.001). The mortality risk associated with cSCa ≥9.0 mg/dL was attenuated among active vitamin D users (pinteraction < 0.001). Patients with faster decline in cSCa showed lower mortality irrespective of baseline cSCa concentrations. These cSCa-mortality associations were stronger for noncardiovascular versus cardiovascular death. In conclusion, lower pre-ESRD cSCa and faster decline in cSCa were consistently and linearly associated with better post-ESRD survival among US veterans, especially for noncardiovascular death. Further studies are needed to determine if correcting hypocalcemia is beneficial or harmful and which intervention is preferred when indicated among patients transitioning to ESRD. © 2018 American Society for Bone and Mineral Research.
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Affiliation(s)
- Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
| | - Christina Park
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
| | - Keiichi Sumida
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Takayuki Hamano
- Department of Comprehensive Kidney Disease Research, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Section, Memphis VA Medical Center, Memphis, TN, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA.,Fielding School of Public Health at UCLA, Los Angeles, CA, USA.,Nephrology Section, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
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26
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Lian IA, Åsberg A. Should total calcium be adjusted for albumin? A retrospective observational study of laboratory data from central Norway. BMJ Open 2018; 8:e017703. [PMID: 29627804 PMCID: PMC5892769 DOI: 10.1136/bmjopen-2017-017703] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVES Albumin-adjusted total calcium is often used as a surrogate marker for free calcium to evaluate hypocalcaemia or hypercalcaemia. Many adjustment formulas based on simple linear regression models have been published, and continue to be used in spite of questionable diagnostic accuracy. In the hope of finding a more pure albumin effect on total calcium, we used multiple linear regression models to adjust for other relevant variables. The regression coefficients of albumin were used to construct local adjustment formulas, and we tested whether the diagnostic accuracy was improved compared with previously published formulas and unadjusted calcium. DESIGN A retrospective hospital laboratory data study. DATA SOURCES The local hospital laboratory data system. SETTING Norway, 2006-2015. PARTICIPANTS 6549 patients above 2 years of age, where free calcium standardised at pH 7.40, total calcium, creatinine, albumin and phosphate had been analysed in a single blood draw, including hospitalised patients and patients from outpatient clinics and general practice. MAIN OUTCOME MEASURES Diagnostic accuracy by Harrell's c and receiver operating characteristic curve analysis, using free calcium standardised at pH 7.40 as a gold standard, in subgroups with estimated glomerular filtration rate (eGFR) ≥60 or <60 mL/min/1.73 m2. RESULTS In the subgroup with eGFR <60 mL/min/1.73 m2, the Harrell's c of unadjusted total calcium (0.801) was significantly larger than those of the local formulas (0.790, p=0.002) and the best formula taken from literature (0.791, p=0.004). In the subgroup with eGFR ≥60 mL/min/1.73 m2, no significant differences were found between these three formulas. CONCLUSIONS Our study shows that the diagnostic accuracy of unadjusted total calcium is superior to several commonly used adjustment formulas, and we suggest that the use of such formulas should be abandoned in clinical practice. If the clinician does not trust total calcium to reflect the calcium status of the patient, free calcium should be measured.
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Affiliation(s)
- Ingrid Alsos Lian
- Department of Clinical Chemistry, St.Olavs hospital, Trondheim, Norway
| | - Arne Åsberg
- Department of Clinical Chemistry, St.Olavs hospital, Trondheim, Norway
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27
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Sakaguchi Y, Hamano T, Kubota K, Oka T, Yamaguchi S, Matsumoto A, Hashimoto N, Mori D, Obi Y, Matsui I, Isaka Y. Anion Gap as a Determinant of Ionized Fraction of Divalent Cations in Hemodialysis Patients. Clin J Am Soc Nephrol 2018; 13:274-281. [PMID: 29180531 PMCID: PMC5967434 DOI: 10.2215/cjn.07930717] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 10/25/2017] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND OBJECTIVES Circulating levels of anions that bind to magnesium and calcium are often altered in patients with CKD. However, it is unknown how these alterations affect the ionized fraction of magnesium and calcium. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This cross-sectional study involved patients on maintenance hemodialysis and patients not on dialysis who visited the outpatient department of nephrology. We collected whole-blood samples to measure ionized magnesium and calcium concentrations. Adjusted anion gap was calculated as an integrative index of unmeasured anions. RESULTS A total of 118 patients on hemodialysis and 112 patients not on dialysis were included. Although the prevalence of hypermagnesemia defined by total magnesium was much higher in patients on hemodialysis than in patients not on dialysis (69% versus 12%; P<0.001), the prevalence of hypermagnesemia defined by ionized magnesium did not differ significantly (13% versus 18%; P=0.28). Among patients on hemodialysis with high total magnesium, 83% had normal or low ionized magnesium. Consequently, the mean ionized fraction of magnesium in patients on hemodialysis was significantly lower than that in patients not on dialysis (51% versus 63%; P<0.001). Similarly, the mean ionized fraction of calcium in patients on hemodialysis was lower than that in patients not on dialysis (55% versus 56%; P<0.001). In patients on hemodialysis who had a higher adjusted anion gap than patients not on dialysis (mean [SD]: 14.1 [2.2] versus 5.1 [3.1]), the ionized fractions of magnesium and calcium were inversely associated with the adjusted anion gap. Furthermore, the anion gap significantly improved predictions of ionized magnesium and calcium in patients on hemodialysis. CONCLUSIONS Anions that accumulate in patients on hemodialysis contribute to the lower ionized fraction of magnesium and calcium. Equations that incorporate the anion gap provide better predictions of ionized magnesium and calcium in patients on hemodialysis.
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Affiliation(s)
| | | | - Keiichi Kubota
- Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan; and
| | - Tatsufumi Oka
- Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan; and
| | - Satoshi Yamaguchi
- Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan; and
| | - Ayumi Matsumoto
- Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan; and
| | - Nobuhiro Hashimoto
- Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan; and
| | - Daisuke Mori
- Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan; and
| | | | - Isao Matsui
- Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan; and
| | - Yoshitaka Isaka
- Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan; and
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28
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Bakon S, Craft J, Christensen M. Hypocalcaemia-induced tetany secondary to total thyroidectomy: a nursing case review. Nurs Crit Care 2017; 24:349-354. [PMID: 28677878 DOI: 10.1111/nicc.12309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 04/27/2017] [Accepted: 06/01/2017] [Indexed: 11/29/2022]
Abstract
Presentations to the emergency department with a diagnosis of hypocalcaemia-induced tetany secondary to total thyroidectomy are rare. A patient presented to the emergency department of a regional Australian hospital with hypocalcaemia-induced tetany. A case study was employed to reflect on the care provided and identify knowledge practice deficits within this unusual patient presentation. Calcium plays a central role within the nervous system and is vital for both cardiac and muscular contraction. The clinical manifestations of electrolyte disturbances such as hypocalcaemia can be life threatening, and therefore, appropriate assessment, monitoring and management are essential to ensure positive patient outcomes. Understanding the importance of calcium imbalance for the emergency and critical care nurse is paramount in preventing complications associated with cardiac conduction and muscle tone, especially the potential for airway compromise. Education is central to this and may include clinical case reviews, the application of pathophysiological presentations of electrolyte imbalance and a review of electrolyte administration guidelines. Understanding the role of calcium within the body will assist emergency and critical care nurses to assess, monitor and intervene appropriately, thereby preventing the life-threatening manifestations of hypocalcaemia.
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Affiliation(s)
- Shannon Bakon
- Queensland University of Technology, Caboolture Campus, Cnr Manley and Tallon Street, Caboolture, Queensland, 4510, Australia.,Emergency Department, Queensland Health, Queensland, 4510, Australia
| | - Judy Craft
- Queensland University of Technology, Caboolture Campus, Cnr Manley and Tallon Street, Caboolture, Queensland, 4510, Australia
| | - Martin Christensen
- Academic Lead for Nursing, Queensland University of Technology, Caboolture Campus, Cnr Manley and Tallon Street, Caboolture, Queensland, 4510, Australia
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29
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Abstract
Disordered calcium balance and homeostasis are common in patients with chronic kidney disease. Such alterations are commonly associated with abnormal bone remodeling, directly and indirectly. Similarly, positive calcium balance may also be a factor in the pathogenesis of extra skeletal soft tissue and arterial calcification. Calcium may directly affect cardiac structure and function through direct effects to alter cell signaling due to abnormal intracellular calcium homeostasis 2) extra-skeletal deposition of calcium and phosphate in the myocardium and small cardiac arterioles, 3) inducing cardiomyocyte hypertrophy through calcium and hormone activation of NFAT signaling mechanisms, and 4) increased aorta calcification resulting in chronic increased afterload leading to hypertrophy. Similarly, calcium may alter vascular smooth muscle cell function and affect cell signaling which may predispose to a proliferative phenotype important in arteriosclerosis and arterial calcification. Thus, disorders of calcium balance and homeostasis due to CKD-MBD may play a role in the high cardiovascular burden observed in patients with CKD.
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Affiliation(s)
- Sharon M Moe
- Indiana University School of Medicine, Division of Nephrology, Indianapolis, IN, United States; Department of Medicine, Roudebush Veterans Affairs Medical Center, Indianapolis, IN, United States.
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30
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Ridefelt P, Helmersson-Karlqvist J. Albumin adjustment of total calcium does not improve the estimation of calcium status. Scand J Clin Lab Invest 2017; 77:442-447. [PMID: 28613958 DOI: 10.1080/00365513.2017.1336568] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND There is a longstanding controversy as to whether plasma measurements of total calcium should be adjusted for albumin concentration, and if so which formulas are the most appropriate. METHODS Ionised calcium, total calcium and albumin results, analysed at the same time at Uppsala University Hospital Laboratory between February 2005 and June 2013, were retrieved from a laboratory information system. The dataset included results from 20,003 patients. Total calcium was albumin-modified by a locally derived formula, based on 3106 patients from the dataset, and formulas from the literature. The agreement between the reference method ionised calcium and unadjusted total calcium and the seven different albumin-modifying calcium formulas, respectively, were compared with intra-class correlation coefficients (ICC). RESULTS Total calcium showed substantial agreement to ionised calcium, ICC 0.85 (95% CI 0.84-0.86) for the whole validation cohort. Albumin-modified calcium by different formulas showed significantly less or equal agreement, however the locally determined formula performed better than formulas taken from the literature. Also, total calcium classified the patient as hypo-normo- or hypercalcemic right in 82% of the patients. The albumin-modified calcium did not classify patients significantly better except in the subgroup hypoalbuminemia (<30 g/L) where the local formula classified the patients slightly better than total calcium. CONCLUSIONS Albumin modification of total calcium determinations is unlikely to add valuable information, and this practice should be abandoned. Ionised calcium should be used more frequently when aberrant results for total calcium are followed up, or in patients with known hypoalbuminemia.
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Affiliation(s)
- Peter Ridefelt
- a Department of Medical Sciences , Clinical Chemistry, Uppsala University , Uppsala , Sweden
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31
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Nakayama Y, Ueda K, Yamagishi SI, Sugiyama M, Yoshida C, Kurokawa Y, Nakamura N, Moriyama T, Kodama G, Minezaki T, Ito S, Nagata A, Taguchi K, Yano J, Kaida Y, Shibatomi K, Fukami K. Compared effects of calcium and sodium polystyrene sulfonate on mineral and bone metabolism and volume overload in pre-dialysis patients with hyperkalemia. Clin Exp Nephrol 2017; 22:35-44. [PMID: 28421299 DOI: 10.1007/s10157-017-1412-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 04/10/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Hyperkalemia is prevalent in end-stage renal disease patients, being involved in life-threatening arrhythmias. Although polystyrene sulfonate (PS) is commonly used for the treatment of hyperkalemia, direct comparison of effects between calcium and sodium PS (CPS and SPS) on mineral and bone metabolism has not yet been studied. METHODS In a randomized and crossover design, 20 pre-dialysis patients with hyperkalemia (>5 mmol/l) received either oral CPS or SPS therapy for 4 weeks. RESULTS After 4-week treatments, there was no significant difference of changes in serum potassium (K) from the baseline (ΔK) between the two groups. However, SPS significantly decreased serum calcium (Ca) and magnesium (Mg) and increased intact parathyroid hormone (iPTH) values, whereas CPS reduced iPTH. ΔiPTH was inversely correlated with ΔCa and ΔMg (r = -0.53 and r = -0.50, respectively). Furthermore, sodium (Na) and atrial natriuretic peptide (ANP) levels were significantly elevated in patients with SPS, but not with CPS, whereas ΔNa and ΔANP were significantly correlated with each other in all the patients. We also found that ΔNa and Δ(Na to chloride ratio) were positively correlated with ΔHCO3-. In artificial colon fluid, CPS increased Ca and decreased Na. Furthermore, SPS greatly reduced K, Mg, and NH3. CONCLUSION Compared with SPS, CPS may be safer for the treatment of hyperkalemia in pre-dialysis patients, because it did not induce hyperparathyroidism or volume overload.
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Affiliation(s)
- Yosuke Nakayama
- Division of Nephrology, Department of Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, Japan
| | - Kaoru Ueda
- Division of Nephrology, Department of Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, Japan.,Department of Rheumatology and Nephrology, Oita Prefectural Hospital, Oita, Japan
| | - Sho-Ichi Yamagishi
- Department of Pathophysiology and Therapeutics of Diabetic Vascular Complications, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Miki Sugiyama
- Division of Nephrology, Department of Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, Japan
| | - Chika Yoshida
- Division of Nephrology, Department of Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, Japan
| | - Yuka Kurokawa
- Division of Nephrology, Department of Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, Japan
| | - Nao Nakamura
- Division of Nephrology, Department of Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, Japan
| | - Tomofumi Moriyama
- Division of Nephrology, Department of Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, Japan
| | - Goh Kodama
- Division of Nephrology, Department of Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, Japan
| | - Tomohisa Minezaki
- Division of Nephrology, Department of Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, Japan
| | - Sakuya Ito
- Division of Nephrology, Department of Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, Japan
| | - Akiko Nagata
- Division of Nephrology, Department of Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, Japan
| | - Kensei Taguchi
- Division of Nephrology, Department of Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, Japan
| | - Junko Yano
- Division of Nephrology, Department of Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, Japan
| | - Yusuke Kaida
- Division of Nephrology, Department of Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, Japan
| | - Kazutaka Shibatomi
- Department of Rheumatology and Nephrology, Oita Prefectural Hospital, Oita, Japan
| | - Kei Fukami
- Division of Nephrology, Department of Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, Japan.
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32
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Affiliation(s)
- Mitchell H Rosner
- Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia
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33
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Bachmann LM, Yu M, Boyd JC, Bruns DE, Miller WG. State of Harmonization of 24 Serum Albumin Measurement Procedures and Implications for Medical Decisions. Clin Chem 2017; 63:770-779. [DOI: 10.1373/clinchem.2016.262899] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 10/31/2016] [Indexed: 01/15/2023]
Abstract
Abstract
BACKGROUND
Measurements of serum and plasma albumin are widely used in medicine, including as indicators of quality of patient care in renal dialysis centers.
METHODS
Pools were prepared from residual patient serum (n = 50) and heparin plasma (n = 48) from patients without renal disease, and serum from patients with kidney failure before hemodialysis (n = 53). Albumin was measured in all samples and in ERM-DA470k/IFCC reference material (RM) by 3 immunochemical, 9 bromcresol green (BCG), and 12 bromcresol purple (BCP) methods.
RESULTS
Two of 3 immunochemical procedures, 5 of 9 BCG, and 10 of 12 BCP methods recovered the RM value within its uncertainty. One immunochemical and 3 BCG methods were biased vs the RM value. Random error components were small for all measurement procedures. The Tina-quant immunochemical method was chosen as the reference measurement procedure based on recovery and results of error analyses. Mean biases for BCG vs Tina-quant were 1.5% to 13.9% and were larger at lower albumin concentrations. BCP methods' mean biases were −5.4% to 1.2% irrespective of albumin concentration. Biases for plasma samples were generally higher than for serum samples for all method types. For most measurement procedures, biases were lower for serum from patients on hemodialysis vs patients without kidney disease.
CONCLUSIONS
Significant differences among immunochemical, BCG, and BCP methods compromise interpretation of serum albumin results. Guidelines and calculations for clinical management of kidney and other diseases must consider the method used for albumin measurement until harmonization can be achieved.
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Affiliation(s)
- Lorin M Bachmann
- Department of Pathology, Virginia Commonwealth University, Richmond, VA
| | - Min Yu
- Department of Pathology, University of Virginia, Charlottesville, VA
| | - James C Boyd
- Department of Pathology, University of Virginia, Charlottesville, VA
| | - David E Bruns
- Department of Pathology, University of Virginia, Charlottesville, VA
| | - W Greg Miller
- Department of Pathology, Virginia Commonwealth University, Richmond, VA
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34
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Obi Y, Nguyen DV, Streja E, Rivara MB, Rhee CM, Lau WL, Chen Y, Kovesdy CP, Mehrotra R, Kalantar-Zadeh K. Development and Validation of a Novel Laboratory-Specific Correction Equation for Total Serum Calcium and Its Association With Mortality Among Hemodialysis Patients. J Bone Miner Res 2017; 32:549-559. [PMID: 27714897 PMCID: PMC5947953 DOI: 10.1002/jbmr.3013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 09/23/2016] [Accepted: 10/05/2016] [Indexed: 12/23/2022]
Abstract
Conventional albumin-corrected calcium is inaccurate in predicting ionized calcium, and hidden hypercalcemia, characterized as high ionized calcium with normal total calcium, is associated with higher mortality in hemodialysis patients. By using a national cohort of hemodialysis patients in the Unites States, a novel laboratory-specific prediction equation composed of total calcium, albumin, and phosphorus was derived from 242 patients in the South Atlantic division (adjusted R2 = 0.80 versus 0.71 for the conventional equation) and then validated among 566 patients in the other divisions (adjusted R2 = 0.79 versus 0.68 for the conventional equation). Compared with the conventional equation, the novel equation showed a greater correlation with intact parathyroid hormone. Its relative performance against the conventional equation was consistent across subgroups based on medications related to calcium metabolism. The novel equation also had a higher sensitivity (57% versus 34%) and an equivalent specificity (99% versus 100%) against ionized hypercalcemia at a cut-off value of 10.2 mg/dL. Sensitivity and specificity at 9.4 mg/dL was 94% and 76% (versus 87% and 82% for the conventional equation), respectively. A survival analysis in 87,779 incident hemodialysis patients showed that among patients who were categorized as having a high-normal calcium status (ie, >9.4 to 10.2 mg/dL) by the conventional equation, there appeared a trend toward higher adjusted mortality risk across higher calcium status defined according to the novel equation. Meanwhile, the mortality risk was consistent across calcium strata defined according to the conventional equation within the categories defined by the novel equation. In conclusion, in comparison to the conventional equation, a novel laboratory-specific correction equation derived for correction of total calcium performs significantly better in ascertaining hidden hypercalcemia in hemodialysis patients, and aids in identifying patients at higher risk for mortality. © 2016 American Society for Bone and Mineral Research.
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Affiliation(s)
- Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Danh V Nguyen
- Biostatistics, Epidemiology, and Research Design Unit, Institute for Clinical and Translational Science, University of California Irvine, Orange, CA, USA.,Department of Medicine, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Matthew B Rivara
- Kidney Research Institute and Harborview Medical Center, Division of Nephrology, University of Washington, Seattle, WA, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Wei Ling Lau
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA, USA
| | - Yanjun Chen
- Biostatistics, Epidemiology, and Research Design Unit, Institute for Clinical and Translational Science, University of California Irvine, Orange, CA, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Section, Memphis VA Medical Center, Memphis, TN, USA
| | - Rajnish Mehrotra
- Kidney Research Institute and Harborview Medical Center, Division of Nephrology, University of Washington, Seattle, WA, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, School of Medicine, Orange, CA, USA.,Fielding School of Public Health at UCLA, Los Angeles, CA, USA.,Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA, USA
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Obi Y, Mehrotra R, Rivara MB, Streja E, Rhee CM, Lau WL, Kovesdy CP, Kalantar-Zadeh K. Hidden Hypercalcemia and Mortality Risk in Incident Hemodialysis Patients. J Clin Endocrinol Metab 2016; 101:2440-9. [PMID: 27045726 PMCID: PMC4891800 DOI: 10.1210/jc.2016-1369] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
CONTEXT Neither uncorrected- nor albumin-corrected total calcium reliably predict ionized calcium in patients with end-stage renal disease. However, little is known about the consequences of inaccurate assessment of calcium concentration using total calcium. OBJECTIVE We hypothesized that hidden hypercalcemia (ie, elevated ionized calcium with normal total calcium) and apparent hypercalcemia (ie, elevated ionized calcium with elevated total calcium) are both associated with increased mortality risk. DESIGN, SETTING, AND PATIENTS We identified 874 incident hemodialysis patients with measured serum ionized calcium, total calcium, albumin, phosphorus, and bicarbonate from October 2007 to December 2011, using data from a large dialysis organization in the United States. EXPOSURES Serum concentrations of ionized calcium and total calcium were measured. MAIN OUTCOME MEASURE The primary outcome was all-cause mortality. RESULTS There was only fair interindex agreement with calcium status between ionized calcium and uncorrected or corrected total calcium (κ = 0.32 and 0.27, respectively). Among patients with high ionized calcium (>1.32 mmol/liter), 88% and 70% patients were incorrectly categorized as being normocalcemic using uncorrected and corrected total calcium, respectively, and were thus considered to have "hidden hypercalcemia." Compared to patients with low-normal ionized calcium (1.16-1.24 mmol/liter), patients with high ionized calcium had a significantly higher mortality risk (adjusted hazard ratio, 1.77; 95% confidence interval, 1.13-2.75). Furthermore, compared to patients with normocalcemia (ionized calcium 1.16-1.32 mmol/liter), those with hidden hypercalcemia by uncorrected and corrected total calcium also had a higher risk for death (adjusted hazard ratio 1.75 [95% confidence interval 1.11-2.75] and 1.80 [95% confidence interval, 1.11-2.90], respectively). CONCLUSION The majority of end-stage renal disease patients with elevated ionized calcium are incorrectly categorized as normocalcemic using conventional total calcium measurements; these patients have a higher death risk. Future research is needed to establish whether reducing ionized calcium concentrations in these patients improves clinical outcomes.
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Affiliation(s)
- Yoshitsugu Obi
- Division of Nephrology and Hypertension (Y.O., E.S., C.M.R., W.L.L., K.K.-Z.), Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, California 92868; Division of Nephrology (R.M., M.B.R.), Kidney Research Institute and Harborview Medical Center, University of Washington, Seattle, Washington 98104; Division of Nephrology (C.P.K.), University of Tennessee Health Science Center, Memphis, Tennessee 38103; Nephrology Section (C.P.K.), Memphis VA Medical Center, Memphis, Tennessee 38104; Fielding School of Public Health at University of California at Los Angeles (K.K.-Z.), Los Angeles, California 90024; and Los Angeles Biomedical Research Institute at Harbor-University of California at Los Angeles (K.K.-Z.), Torrance, California 90502
| | - Rajnish Mehrotra
- Division of Nephrology and Hypertension (Y.O., E.S., C.M.R., W.L.L., K.K.-Z.), Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, California 92868; Division of Nephrology (R.M., M.B.R.), Kidney Research Institute and Harborview Medical Center, University of Washington, Seattle, Washington 98104; Division of Nephrology (C.P.K.), University of Tennessee Health Science Center, Memphis, Tennessee 38103; Nephrology Section (C.P.K.), Memphis VA Medical Center, Memphis, Tennessee 38104; Fielding School of Public Health at University of California at Los Angeles (K.K.-Z.), Los Angeles, California 90024; and Los Angeles Biomedical Research Institute at Harbor-University of California at Los Angeles (K.K.-Z.), Torrance, California 90502
| | - Matthew B Rivara
- Division of Nephrology and Hypertension (Y.O., E.S., C.M.R., W.L.L., K.K.-Z.), Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, California 92868; Division of Nephrology (R.M., M.B.R.), Kidney Research Institute and Harborview Medical Center, University of Washington, Seattle, Washington 98104; Division of Nephrology (C.P.K.), University of Tennessee Health Science Center, Memphis, Tennessee 38103; Nephrology Section (C.P.K.), Memphis VA Medical Center, Memphis, Tennessee 38104; Fielding School of Public Health at University of California at Los Angeles (K.K.-Z.), Los Angeles, California 90024; and Los Angeles Biomedical Research Institute at Harbor-University of California at Los Angeles (K.K.-Z.), Torrance, California 90502
| | - Elani Streja
- Division of Nephrology and Hypertension (Y.O., E.S., C.M.R., W.L.L., K.K.-Z.), Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, California 92868; Division of Nephrology (R.M., M.B.R.), Kidney Research Institute and Harborview Medical Center, University of Washington, Seattle, Washington 98104; Division of Nephrology (C.P.K.), University of Tennessee Health Science Center, Memphis, Tennessee 38103; Nephrology Section (C.P.K.), Memphis VA Medical Center, Memphis, Tennessee 38104; Fielding School of Public Health at University of California at Los Angeles (K.K.-Z.), Los Angeles, California 90024; and Los Angeles Biomedical Research Institute at Harbor-University of California at Los Angeles (K.K.-Z.), Torrance, California 90502
| | - Connie M Rhee
- Division of Nephrology and Hypertension (Y.O., E.S., C.M.R., W.L.L., K.K.-Z.), Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, California 92868; Division of Nephrology (R.M., M.B.R.), Kidney Research Institute and Harborview Medical Center, University of Washington, Seattle, Washington 98104; Division of Nephrology (C.P.K.), University of Tennessee Health Science Center, Memphis, Tennessee 38103; Nephrology Section (C.P.K.), Memphis VA Medical Center, Memphis, Tennessee 38104; Fielding School of Public Health at University of California at Los Angeles (K.K.-Z.), Los Angeles, California 90024; and Los Angeles Biomedical Research Institute at Harbor-University of California at Los Angeles (K.K.-Z.), Torrance, California 90502
| | - Wei Ling Lau
- Division of Nephrology and Hypertension (Y.O., E.S., C.M.R., W.L.L., K.K.-Z.), Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, California 92868; Division of Nephrology (R.M., M.B.R.), Kidney Research Institute and Harborview Medical Center, University of Washington, Seattle, Washington 98104; Division of Nephrology (C.P.K.), University of Tennessee Health Science Center, Memphis, Tennessee 38103; Nephrology Section (C.P.K.), Memphis VA Medical Center, Memphis, Tennessee 38104; Fielding School of Public Health at University of California at Los Angeles (K.K.-Z.), Los Angeles, California 90024; and Los Angeles Biomedical Research Institute at Harbor-University of California at Los Angeles (K.K.-Z.), Torrance, California 90502
| | - Csaba P Kovesdy
- Division of Nephrology and Hypertension (Y.O., E.S., C.M.R., W.L.L., K.K.-Z.), Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, California 92868; Division of Nephrology (R.M., M.B.R.), Kidney Research Institute and Harborview Medical Center, University of Washington, Seattle, Washington 98104; Division of Nephrology (C.P.K.), University of Tennessee Health Science Center, Memphis, Tennessee 38103; Nephrology Section (C.P.K.), Memphis VA Medical Center, Memphis, Tennessee 38104; Fielding School of Public Health at University of California at Los Angeles (K.K.-Z.), Los Angeles, California 90024; and Los Angeles Biomedical Research Institute at Harbor-University of California at Los Angeles (K.K.-Z.), Torrance, California 90502
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension (Y.O., E.S., C.M.R., W.L.L., K.K.-Z.), Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, California 92868; Division of Nephrology (R.M., M.B.R.), Kidney Research Institute and Harborview Medical Center, University of Washington, Seattle, Washington 98104; Division of Nephrology (C.P.K.), University of Tennessee Health Science Center, Memphis, Tennessee 38103; Nephrology Section (C.P.K.), Memphis VA Medical Center, Memphis, Tennessee 38104; Fielding School of Public Health at University of California at Los Angeles (K.K.-Z.), Los Angeles, California 90024; and Los Angeles Biomedical Research Institute at Harbor-University of California at Los Angeles (K.K.-Z.), Torrance, California 90502
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Torres A, Torregrosa V, Marcen R, Campistol JM, Arias M, Hernández D, Fernández C, Esforzado N, Paschoalin R, Pérez N, García AI, Del Amo M, Pomés J, González Rinne A, Marrero D, Pérez E, Henríquez F, Díaz JM, Silva I, López V, Perello M, Ramos D, Beneyto I, Cruzado JM, Martínez Castelao A, Bravo J, Rodríguez M, Díaz C, Crespo J, Anaya F, Rodríguez ML, Cubero JJ, Pascual P, Romero R, Andrés Belmonte A, Checa MD, Jiménez C, Escuin F, Crespo M, Mir M, Gómez G, Bayes B, González MJ, Gutiérrez A, Cuberes M, Rodríguez Benoit A, García T, Llamas F, Ortega A, Conde JL, Gómez Alamillo C. Mineral metabolism disorders, vertebral fractures and aortic calcifications in stable kidney transplant recipients: The role of gender (EMITRAL study). Nefrologia 2016; 36:255-67. [PMID: 27133898 DOI: 10.1016/j.nefro.2016.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 03/06/2016] [Accepted: 03/11/2016] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The relationship between mineral metabolism disorders, bone fractures and vascular calcifications in kidney transplant recipients has not been established. METHOD We performed a cross-sectional study in 727 stable recipients from 28 Spanish transplant clinics. Mineral metabolism parameters, the semi-quantification of vertebral fractures and abdominal aortic calcifications were determined centrally. RESULTS Vitamin D deficiency (25OHD3<15ng/ml) was more common in female recipients at CKD-T stages I-III (29.6% vs 44.4%; p=0.003). The inverse and significant correlation between 25OHD3 and PTH was gender-specific and women exhibited a steeper slope than men (p=0.01). Vertebral fractures (VFx) with deformity grade ≥2 were observed in 15% of recipients. Factors related to VFx differed by gender; in males, age (OR 1.04; 95% CI 1.01-1.06) and CsA treatment (OR: 3.2; 95% CI: 1.6-6.3); in females, age (OR 1.07; 95% CI: 1.03-1.12) and PTH levels (OR per 100pg/ml increase: 1.27; 95% CI: 1.043-1.542). Abdominal aortic calcifications were common (67.2%) and related to classical risk factors but not to mineral metabolism parameters. CONCLUSIONS Vitamin D deficiency is more common among female kidney transplant recipients at earlier CKD-T stages, and it contributes to secondary hyperparathyroidism. Prevalent vertebral fractures are only related to high serum PTH levels in female recipients.
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Affiliation(s)
- Armando Torres
- Servicio de Nefrología, HospitalUniversitario de Canarias, CIBICAN, Universidad de La Laguna, RedInRen RD12/0021/0008-Instituto de Salud Carlos III, Tenerife, Spain.
| | - Vicens Torregrosa
- Unidad de Nefrología y Trasplante Renal, Hospital Clinic, RedInRen, RD12/0021/0028, Instituto de Salud Carlos III, Barcelona, Spain
| | - Roberto Marcen
- Servicio de Nefrología, Hospital Universitario Ramón y Cajal (RedInRen, RD12/0021/0020-Instituto de Salud Carlos III), Madrid, Spain
| | - Josep María Campistol
- Unidad de Nefrología y Trasplante Renal, Hospital Clinic, RedInRen, RD12/0021/0028, Instituto de Salud Carlos III, Barcelona, Spain
| | - Manuel Arias
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, RedInRen RD12/0021/0007-Instituto de Salud Carlos III, Santander, Spain
| | - Domingo Hernández
- Servicio de Nefrología, Hospital Regional Carlos Haya, Universidad de Málaga (IBIMA), RedInRen RD12/0021/0015-Instituto de Salud Carlos III, Málaga, Spain
| | - Constantino Fernández
- Servicio de Nefrología, Complexo Hospitalario Universitario Juan Canalejo, A Coruña , Spain
| | - Nuria Esforzado
- Unidad de Nefrología y Trasplante Renal, Hospital Clinic, RedInRen, RD12/0021/0028, Instituto de Salud Carlos III, Barcelona, Spain
| | - Raphael Paschoalin
- Unidad de Nefrología y Trasplante Renal, Hospital Clinic, RedInRen, RD12/0021/0028, Instituto de Salud Carlos III, Barcelona, Spain
| | - Nuria Pérez
- Unidad de Nefrología y Trasplante Renal, Hospital Clinic, RedInRen, RD12/0021/0028, Instituto de Salud Carlos III, Barcelona, Spain
| | - Ana Isabel García
- Unidad de Nefrología y Trasplante Renal, Hospital Clinic, RedInRen, RD12/0021/0028, Instituto de Salud Carlos III, Barcelona, Spain
| | - Montserrat Del Amo
- Unidad de Nefrología y Trasplante Renal, Hospital Clinic, RedInRen, RD12/0021/0028, Instituto de Salud Carlos III, Barcelona, Spain
| | - Jaume Pomés
- Unidad de Nefrología y Trasplante Renal, Hospital Clinic, RedInRen, RD12/0021/0028, Instituto de Salud Carlos III, Barcelona, Spain
| | - Ana González Rinne
- Servicio de Nefrología, HospitalUniversitario de Canarias, CIBICAN, Universidad de La Laguna, RedInRen RD12/0021/0008-Instituto de Salud Carlos III, Tenerife, Spain
| | - Domingo Marrero
- Servicio de Nefrología, HospitalUniversitario de Canarias, CIBICAN, Universidad de La Laguna, RedInRen RD12/0021/0008-Instituto de Salud Carlos III, Tenerife, Spain
| | - Estefanía Pérez
- Servicio de Nefrología, HospitalUniversitario de Canarias, CIBICAN, Universidad de La Laguna, RedInRen RD12/0021/0008-Instituto de Salud Carlos III, Tenerife, Spain
| | - Fernando Henríquez
- Servicio de Nefrología, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain
| | - Juan Manuel Díaz
- Servicio de Nefrología, Fundació Puigvert I.U.N.A, Barcelona, Spain
| | - Irene Silva
- Servicio de Nefrología, Fundació Puigvert I.U.N.A, Barcelona, Spain
| | - Verónica López
- Servicio de Nefrología, Hospital Regional Carlos Haya, Universidad de Málaga (IBIMA), RedInRen RD12/0021/0015-Instituto de Salud Carlos III, Málaga, Spain
| | - Manuel Perello
- Servicio de Nefrología, Hospital Vall D́Hebrón, Barcelona, Spain
| | - David Ramos
- Servicio de Nefrología, Hospital Universitario La Fe, Valencia, Spain
| | - Isabel Beneyto
- Servicio de Nefrología, Hospital Universitario La Fe, Valencia, Spain
| | - José María Cruzado
- Servicio de Nefrología, Hospital Universitario de Bellvitge, Barcelona, Spain
| | | | - Juan Bravo
- Servicio de Nefrología, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Minerva Rodríguez
- Servicio de Nefrología, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Carmen Díaz
- Servicio de Nefrología, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Josep Crespo
- Servicio de Nefrología, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Fernando Anaya
- Servicio de Nefrología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - María Luisa Rodríguez
- Servicio de Nefrología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Juan José Cubero
- Servicio de Nefrología, Hospital Regional Universitario Infanta Cristina, Badajoz, Spain
| | - Pilar Pascual
- Servicio de Nefrología, Hospital Clínico Universitario de Valladolid, Spain
| | - Rafael Romero
- Servicio de Nefrología, Complexo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | | | - María Dolores Checa
- Servicio de Nefrología, Centro Hospitalario Universitario Insular Materno Infantil, Las Palmas de Gran Canaria, Spain
| | - Carlos Jiménez
- Servicio de Nefrología, Hospital Universitario La Paz, Madrid, Spain
| | - Fernando Escuin
- Servicio de Nefrología, Hospital Universitario La Paz, Madrid, Spain
| | - Marta Crespo
- Servicio de Nefrología, Hospital del Mar, Barcelona, Spain
| | - Marisa Mir
- Servicio de Nefrología, Hospital del Mar, Barcelona, Spain
| | - Gonzalo Gómez
- Servicio de Nefrología, Hospital Universitario Son Dureta, Palma de Mallorca, Spain
| | - Beatriz Bayes
- Servicio de Nefrología, Hospital Universitario Germans Trias I Pujol, Barcelona, Spain
| | - María José González
- Servicio de Nefrología, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Alex Gutiérrez
- Servicio de Nefrología, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Marta Cuberes
- Servicio de Nefrología, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Teresa García
- Servicio de Nefrología, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | - Francisco Llamas
- Servicio de Nefrología, Complejo Hospitalario y Universitario de Albacete, Spain
| | - Agustín Ortega
- Servicio de Nefrología, Complejo Hospitalario y Universitario de Albacete, Spain
| | - José Luis Conde
- Servicio de Nefrología, Hospital Complejo Hospitario de Toledo, Spain
| | - Carlos Gómez Alamillo
- Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, RedInRen RD12/0021/0007-Instituto de Salud Carlos III, Santander, Spain
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Kaku Y, Ookawara S, Miyazawa H, Ito K, Ueda Y, Hirai K, Hoshino T, Mori H, Yoshida I, Morishita Y, Tabei K. New Method for the Approximation of Corrected Calcium Concentrations in Chronic Kidney Disease Patients. Ther Apher Dial 2016; 20:46-52. [DOI: 10.1111/1744-9987.12351] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Revised: 06/15/2015] [Accepted: 06/18/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Yoshio Kaku
- Division of Nephrology; First Department of Integrated Medicine; Saitama Medical Center, Jichi Medical University; Saitama Japan
| | - Susumu Ookawara
- Division of Nephrology; First Department of Integrated Medicine; Saitama Medical Center, Jichi Medical University; Saitama Japan
| | - Haruhisa Miyazawa
- Division of Nephrology; First Department of Integrated Medicine; Saitama Medical Center, Jichi Medical University; Saitama Japan
| | - Kiyonori Ito
- Division of Nephrology; First Department of Integrated Medicine; Saitama Medical Center, Jichi Medical University; Saitama Japan
| | - Yuichirou Ueda
- Division of Nephrology; First Department of Integrated Medicine; Saitama Medical Center, Jichi Medical University; Saitama Japan
| | - Keiji Hirai
- Division of Nephrology; First Department of Integrated Medicine; Saitama Medical Center, Jichi Medical University; Saitama Japan
| | - Taro Hoshino
- Division of Nephrology; First Department of Integrated Medicine; Saitama Medical Center, Jichi Medical University; Saitama Japan
| | - Honami Mori
- Division of Nephrology; First Department of Integrated Medicine; Saitama Medical Center, Jichi Medical University; Saitama Japan
| | - Izumi Yoshida
- Division of Nephrology; First Department of Integrated Medicine; Saitama Medical Center, Jichi Medical University; Saitama Japan
| | - Yoshiyuki Morishita
- Division of Nephrology; First Department of Integrated Medicine; Saitama Medical Center, Jichi Medical University; Saitama Japan
| | - Kaoru Tabei
- Division of Nephrology; First Department of Integrated Medicine; Saitama Medical Center, Jichi Medical University; Saitama Japan
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Kaku Y, Ookawara S, Miyazawa H, Ito K, Ueda Y, Hirai K, Hoshino T, Mori H, Yoshida I, Morishita Y, Tabei K. Approximation of Corrected Calcium Concentrations in Advanced Chronic Kidney Disease Patients with or without Dialysis Therapy. NEPHRON EXTRA 2015; 5:39-49. [PMID: 26557841 PMCID: PMC4592511 DOI: 10.1159/000437215] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background The following calcium (Ca) correction formula (Payne) is conventionally used for serum Ca estimation: corrected total Ca (TCa) (mg/dl) = TCa (mg/dl) + [4 – albumin (g/dl)]; however, it is inapplicable to advanced chronic kidney disease (CKD) patients. Methods 1,922 samples in CKD G4 + G5 patients and 341 samples in CKD G5D patients were collected. Levels of TCa (mg/day), ionized Ca2+ (iCa2+) (mmol/l) and other clinical parameters were measured. We assumed the corrected TCa to be equal to eight times the iCa2+ value (measured corrected TCa). We subsequently performed stepwise multiple linear regression analysis using the clinical parameters. Results The following formula was devised from multiple linear regression analysis. For CKD G4 + G5 patients: approximated corrected TCa (mg/dl) = TCa + 0.25 × (4 – albumin) + 4 × (7.4 – pH) + 0.1 × (6 – P) + 0.22. For CKD G5D patients: approximated corrected TCa (mg/dl) = TCa + 0.25 × (4 – albumin) + 0.1 × (6 – P) + 0.05 × (24 – HCO3-) + 0.35. Receiver operating characteristic analysis showed the high values of the area under the curve of approximated corrected TCa for the detection of measured corrected TCa ≥8.4 mg/dl and ≤10.4 mg/dl for each CKD sample. Both intraclass correlation coefficients for each CKD sample demonstrated superior agreement using the new formula compared to the previously reported formulas. Conclusion Compared to other formulas, the approximated corrected TCa values calculated from the new formula for patients with CKD G4 + G5 and CKD G5D demonstrates superior agreement with the measured corrected TCa.
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Affiliation(s)
- Yoshio Kaku
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Susumu Ookawara
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Haruhisa Miyazawa
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kiyonori Ito
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yuichiro Ueda
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Keiji Hirai
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Taro Hoshino
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Honami Mori
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Izumi Yoshida
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yoshiyuki Morishita
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kaoru Tabei
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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Abstract
Sudden cardiac death (SCD) accounts for a quarter of all deaths in end-stage renal disease (ESRD) patients. While causative mechanisms of SCD in this high risk population remain poorly defined, interaction of the vulnerable myocardium with dialysis-related arrhythmic triggers is thought to play a major role. Recent evidence suggests that dialysis-induced derangement of calcium concentrations contributes to the increased risk of all-cause and cardiovascular mortality, vascular calcification, and SCD. Current KDIGO guidelines recommend avoiding high dialysate calcium concentrations as a precaution against adverse outcomes of increased calcium burden and vascular calcification. Conversely, low calcium concentration is also implicated in the development of SCD via increased QT dispersion and prolonged QT interval. Consequently, the optimal dialysate calcium concentration in dialysis patients remains debated and further studies are needed to establish the best strategy for managing calcium in dialysis patients.
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Affiliation(s)
- Esther D Kim
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Rulan S Parekh
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,The Hospital for Sick Children and the University Health Network, Toronto, Ontario, Canada.,Department of Pediatrics and Medicine, School of Medicine, University of Toronto, Toronto, Ontario, Canada
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Brunelli SM, Dluzniewski PJ, Cooper K, Do TP, Sibbel S, Bradbury BD. Management of serum calcium reductions among patients on hemodialysis following cinacalcet initiation. Pharmacoepidemiol Drug Saf 2015; 24:1058-67. [PMID: 26238994 DOI: 10.1002/pds.3845] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 06/10/2015] [Accepted: 07/07/2015] [Indexed: 11/12/2022]
Abstract
PURPOSE Cinacalcet is indicated for treatment of secondary hyperparathyroidism in patients receiving hemodialysis. Cinacalcet reduces serum calcium concentrations by decreasing parathyroid hormone secretion, but the frequency and degree of calcium reduction following cinacalcet initiation, subsequent physician response, and ultimate calcium recovery in clinical practice are not well described. METHODS Patients receiving hemodialysis at a large dialysis organization who enrolled in the organization's prescription benefits service and initiated cinacalcet at serum calcium ≥8.4 mg/dL were studied (N = 13 723). Patients were categorized by whether they experienced a reduction in calcium to <8.4 mg/dL and to what level (<7.5, 7.5-7.9, and 8.0-8.3 mg/dL). Baseline characteristics, frequency of subsequent intervention, and calcium recovery were compared. RESULTS Of those who experienced a reduction in calcium to <8.4 mg/dL (n = 6437 [46.9%]), 6.6% had calcium <7.5 mg/dL and 24.5% had calcium 7.5-7.9 mg/dL, while the majority (68.9%) had a level of 8-8.3 mg/dL. Higher baseline parathyroid hormone and alkaline phosphatase were associated with lower resultant calcium. Among patients with calcium reductions, 45.6-63.5% received one or more directed clinical therapeutic responses, including 15.6-28.4% for whom cinacalcet was discontinued; the majority of patients recovered to calcium ≥8.4 mg/dL within 90 days of first detection. Only modest differences in recovery were noted between patients who did and did not receive any therapeutic response and patients who did and did not discontinue cinacalcet. CONCLUSION Serum calcium reductions following cinacalcet initiation were common; declines <7.5 mg/dL were infrequent. Calcium recovery occurred in the majority of patients, with or without therapeutic intervention.
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Affiliation(s)
| | | | | | - Thy P Do
- Amgen Inc., Thousand Oaks, CA, USA
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Jean G, Granjon S, Zaoui E, Deleaval P, Hurot JM, Lorriaux C, Mayor B, Chazot C. Usefulness and feasibility of measuring ionized calcium in haemodialysis patients. Clin Kidney J 2015; 8:378-87. [PMID: 26251703 PMCID: PMC4515894 DOI: 10.1093/ckj/sfv039] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 05/04/2015] [Indexed: 12/21/2022] Open
Abstract
Background Measuring blood calcium level is recommended in haemodialysis (HD) patients. The Kidney Disease Improving Global Outcomes position states that the measurement of ionized calcium (ICa) level is preferred, but in the clinical setting, due to technical difficulties, total calcium (tCa) level is preferred to ICa. Aim The aim of this study was to test the possibility of delayed ICa analysis using frozen serum, and so to identify the factors associated with predialysis ICa level and compare the ability of tCa and Alb-Ca to predict ICa level and finally to compare the survival rate according to the three calcium measurements. Methods All prevalent HD patients, dialysed by a native AV fistula in a 3 × 4 to 3 × 8 h schedule, had their predialysis ICa, tCa and Alb-Ca levels and usual mid-week biology recorded. Intergroup comparisons between ICa quartile were performed. Bland–Altman plots and linear regression were used to assess the differences between 30 fresh and frozen samples. Survival analyses were performed using ICa and tCa levels. Results Comparing fresh blood and frozen serum samples, linear regression (y = 0.98 + 0.02, r = 0.961) showed that the two methods were quite identical with the same mean ICa value (1.1 ± 0.1 mmol/L, P = 0.45). A total of 160 HD patients were included in the study. Hypocalcaemia, using ICa values, was highly prevalent in our population (40%) whereas hypercalcaemia was observed only in three cases (1.8%). In predicting ICa hypocalcaemia (<1.12 mmol/L, n = 64), the use of tCa was accurate in 48.4% of patients, and the use of Alb-Ca was accurate in only 17.2% of patients; tCa was not a predictive factor for hypercalcaemia (ICa > 1.32 mmol/L, n = 3); Alb-Ca value predicted hypercalcaemia in 2/3 of the patients. In predicting normocalcaemia, the use of tCa values was correct in 92.4% of patients and the use of Alb-Ca values in 88.1% of patients; only younger age (P = 0.03) and female sex (P = 0.01) were associated with higher ICa quartile. None of the three calcium measures was significantly associated with survival rate using log-rank and Cox models adjusted for age, dialysis vintage, diabetes and sex. Conclusion In the present study, we report that (1) delayed ICa measure is feasible in dialysis patients using a freezing technique, (2) hypocalcaemia is highly prevalent in HD patients and poorly predicted by Alb-Ca level, (3) the main factor associated with ICa level is sex of the individual and (4) calcaemia is not associated with survival rate using any of the three methods.
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Affiliation(s)
- Guillaume Jean
- Dialysis, NephroCare Tassin-Charcot, Sainte Foy-Les-Lyon, France
| | - Samuel Granjon
- Biochemistry Department, Laboratoire Novescia, Sainte Foy Les Lyon, Rhone Alpes, France
| | - Eric Zaoui
- Biochemistry Department, Laboratoire Novescia, Sainte Foy Les Lyon, Rhone Alpes, France
| | - Patrik Deleaval
- Dialysis, NephroCare Tassin-Charcot, Sainte Foy-Les-Lyon, France
| | - Jean-Marc Hurot
- Dialysis, NephroCare Tassin-Charcot, Sainte Foy-Les-Lyon, France
| | | | - Brice Mayor
- Dialysis, NephroCare Tassin-Charcot, Sainte Foy-Les-Lyon, France
| | - Charles Chazot
- Dialysis, NephroCare Tassin-Charcot, Sainte Foy-Les-Lyon, France
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Rivara MB, Ravel V, Kalantar-Zadeh K, Streja E, Lau WL, Nissenson AR, Kestenbaum B, de Boer IH, Himmelfarb J, Mehrotra R. Uncorrected and Albumin-Corrected Calcium, Phosphorus, and Mortality in Patients Undergoing Maintenance Dialysis. J Am Soc Nephrol 2015; 26:1671-81. [PMID: 25613037 DOI: 10.1681/asn.2014050472] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 09/02/2014] [Indexed: 12/20/2022] Open
Abstract
Uncorrected serum calcium concentration is the first mineral metabolism metric planned for use as a quality measure in the United States ESRD population. Few studies in patients undergoing either peritoneal dialysis (PD) or hemodialysis (HD) have assessed the association of uncorrected serum calcium concentration with clinical outcomes. We obtained data from 129,076 patients on dialysis (PD, 10,066; HD, 119,010) treated in DaVita, Inc. facilities between July 1, 2001, and June 30, 2006. After adjustment for potential confounders, uncorrected serum calcium <8.5 and ≥10.2 mg/dl were associated with excess mortality in patients on PD or HD (comparison group uncorrected calcium 9.0 to <9.5 mg/dl). Additional adjustment for serum albumin concentration substantially attenuated the all-cause mortality hazard ratios (HRs) associated with uncorrected calcium <8.5 mg/dl (HR, 1.29; 95% confidence interval [95% CI], 1.16 to 1.44 for PD; HR, 1.17; 95% CI, 1.13 to 1.20 for HD) and amplified the HRs associated with calcium ≥10.2 mg/dl (HR, 1.65; 95% CI, 1.42 to 1.91 for PD; HR, 1.59; 95% CI, 1.53 to 1.65 for HD). Albumin-corrected calcium ≥10.2 mg/dl and serum phosphorus ≥6.4 mg/dl were also associated with increased risk for death, irrespective of dialysis modality. In summary, in a large nationally representative cohort of patients on dialysis, abnormalities in markers of mineral metabolism, particularly high concentrations of serum calcium and phosphorus, were associated with increased mortality risk. Additional studies are needed to investigate whether control of hypercalcemia and hyperphosphatemia in patients undergoing dialysis results in improved clinical outcomes.
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Affiliation(s)
- Matthew B Rivara
- Kidney Research Institute, University of Washington, Seattle, Washington;
| | - Vanessa Ravel
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine Medical Center, Irvine, California
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine Medical Center, Irvine, California; Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine Medical Center, Irvine, California; Fielding School of Public Health, University of California Los Angeles, Los Angeles, California
| | - Wei Ling Lau
- Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California
| | - Allen R Nissenson
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California; and DaVita, Inc., El Segundo, California
| | - Bryan Kestenbaum
- Kidney Research Institute, University of Washington, Seattle, Washington
| | - Ian H de Boer
- Kidney Research Institute, University of Washington, Seattle, Washington
| | | | - Rajnish Mehrotra
- Kidney Research Institute, University of Washington, Seattle, Washington
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Lam V, Dhaliwal SS, Mamo JC. Adjustment of ionized calcium concentration for serum pH is not a valid marker of calcium homeostasis: implications for identifying individuals at risk of calcium metabolic disorders. Ann Clin Biochem 2013; 50:224-9. [PMID: 23615406 DOI: 10.1177/0004563212473747] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Ionized calcium (iCa) is the biologically active form of this micronutrient. Serum determination of iCa is measured via ion-electrode potentiometry (IEP) and reporting iCa relative to pH 7.4 is normally utilized to avoid the potential confounding effects of ex vivo changes to serum pH. Adjustment of iCa for pH has not been adequately justified. METHODS In this study, utilizing carefully standardized protocols for blood collection, the preparation of serum and controlling time of collection-to-analysis, we determined serum iCa and pH utilizing an IEP-analyser hosted at an accredited diagnostic laboratory. RESULTS Regression analysis of unadjusted-iCa (iCa(raw)) concentration versus pH was described by linear regression and accounted for 37% of serum iCa(raw) variability. iCa(raw) was then expressed at pH 7.4 by either adjusting iCa(raw) based on the linear regression equation describing the association of iCa with serum pH (iCa(regr)) or using IEP coded published normative equations (iCa(pub)). iCa(regr) was comparable to iCa(raw), indicating that blood collection and processing methodologies were sound. However, iCa(pub) yielded values that were significantly lower than iCa(raw). iCa(pub) did not identify 15% subjects who had greater than desirable serum concentration of iCa based on iCa(raw). Sixty percent of subjects with low levels of iCa(raw) were also not detected by iCa(pub). Determination of the kappa value measure of agreement for iCa(raw) versus iCa(pub) showed relatively poor concordance (κ = 0.42). CONCLUSIONS With simple protocols that avoid sampling artefacts, expressing iCa(raw) is likely to be a more valid and physiologically relevant marker of calcium homeostasis than is iCa(pub).
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Affiliation(s)
- Virginie Lam
- School of Public Health and the Curtin Health Innovation Research Institute, Curtin University, Perth, Western Australia
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44
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Chai Y, Carlier A, Bolander J, Roberts S, Geris L, Schrooten J, Van Oosterwyck H, Luyten F. Current views on calcium phosphate osteogenicity and the translation into effective bone regeneration strategies. Acta Biomater 2012; 8:3876-87. [PMID: 22796326 DOI: 10.1016/j.actbio.2012.07.002] [Citation(s) in RCA: 158] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2012] [Revised: 06/28/2012] [Accepted: 07/03/2012] [Indexed: 02/06/2023]
Abstract
Calcium phosphate (CaP) has traditionally been used for the repair of bone defects because of its strong resemblance to the inorganic phase of bone matrix. Nowadays, a variety of natural or synthetic CaP-based biomaterials are produced and have been extensively used for dental and orthopaedic applications. This is justified by their biocompatibility, osteoconductivity and osteoinductivity (i.e. the intrinsic material property that initiates de novo bone formation), which are attributed to the chemical composition, surface topography, macro/microporosity and the dissolution kinetics. However, the exact molecular mechanism of action is unknown. This review paper first summarizes the most important aspects of bone biology in relation to CaP and the mechanisms of bone matrix mineralization. This is followed by the research findings on the effects of calcium (Ca²⁺) and phosphate (PO₄³⁻) ions on the migration, proliferation and differentiation of osteoblasts during in vivo bone formation and in vitro culture conditions. Further, the rationale of using CaP for bone regeneration is explained, focusing thereby specifically on the material's osteoinductive properties. Examples of different material forms and production techniques are given, with the emphasis on the state-of-the art in fine-tuning the physicochemical properties of CaP-based biomaterials for improved bone induction and the use of CaP as a delivery system for bone morphogenetic proteins. The use of computational models to simulate the CaP-driven osteogenesis is introduced as part of a bone tissue engineering strategy in order to facilitate the understanding of cell-material interactions and to gain further insight into the design and optimization of CaP-based bone reparative units. Finally, limitations and possible solutions related to current experimental and computational techniques are discussed.
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45
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Endres DB. Investigation of hypercalcemia. Clin Biochem 2012; 45:954-63. [DOI: 10.1016/j.clinbiochem.2012.04.025] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Revised: 04/19/2012] [Accepted: 04/26/2012] [Indexed: 02/06/2023]
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Fibroblast Growth Factor and Mineral Metabolism Parameters among Prevalent Kidney Transplant Patients. Int J Nephrol 2012; 2012:490623. [PMID: 22811905 PMCID: PMC3395143 DOI: 10.1155/2012/490623] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 04/23/2012] [Indexed: 12/11/2022] Open
Abstract
Background. Chronic kidney disease (CKD) related mineral bone disorders persist after kidney transplantation, but little is known about the relationship between fibroblast growth factor-23 (FGF-23) and mineral metabolism in prevalent post-transplant patients. Objectives. To examine mineral metabolism parameters and their relationship to FGF-23 and parathyroid hormone (PTH) in prevalent kidney transplant patients. Methods. Cross-sectional study of 106 kidney transplant patients enrolled November 2005–October 2009 at Tufts Medical Center (TMC), Boston. Results. The prevalence of hypophosphatemia was 34%, hypercalcemia 3%, and elevated PTH levels 66%, at a median (25th–75th percentile) duration of 12.8 (7.5–30.9) months post-transplant. Males had significantly higher levels of PTH (P = 0.04) and lower levels of serum phosphate
(P = 0.002). Serum PTH levels did not relate to eGFR, corrected calcium levels or serum phosphate. FGF-23 levels were above the reference limits in 7% of patients; higher levels were associated with higher serum phosphate and PTH levels after adjustment for transplant kidney function. Conclusion. FGF-23 is an important driver of mineral metabolism in prevalent transplant patients. Its modulatory role in mineral metabolism homeostasis may be heightened as feedback suppression of PTH is disturbed. Its role in long term cardiovascular and graft outcomes needs further study.
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47
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Kavanagh DO, Fitzpatrick P, Myers E, Kennelly R, Skehan SJ, Gibney RG, Hill ADK, Evoy D, McDermott EW. A predictive model of suitability for minimally invasive parathyroid surgery in the treatment of primary hyperparathyroidism [corrected]. World J Surg 2012; 36:1175-1181. [PMID: 22170475 DOI: 10.1007/s00268-011-1377-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Improved preoperative localizing studies have facilitated minimally invasive approaches in the treatment of primary hyperparathyroidism (PHPT). Success depends on the ability to reliably select patients who have PHPT due to single-gland disease. We propose a model encompassing preoperative clinical, biochemical, and imaging studies to predict a patient's suitability for minimally invasive surgery. METHODS For the purposes of the present study, 180 consecutive patients were included for analysis. A 5-variable model based on preoperative ionized serum calcium (>1.4 mmol/l), intact parathyroid hormone level (≥ 2 times the upper limit of normal), positive sestamibi scan for a single affected gland, positive ultrasound scan for a single gland, and concordance between the two imaging modalities for single-gland disease at a similar location was employed, where a score of 1 was allocated for each variable present. RESULTS Of the 180 patients, 62 (34%) underwent bilateral exploration, 63 (36%) underwent unilateral exploration, and 55 (30%) underwent minimally invasive parathyroidectomy. The results showed that 92% had single-gland disease, 3% had double adenomas, and 5% had hyperplasia. Biochemical cure was achieved in 98.9%. Mean follow-up was 153 days (range: 80-342 days). With the predictive scoring model, a score of ≥ 3 had a positive predictive value of 100% for single-gland disease. CONCLUSIONS A scoring model encompassing preoperative biochemical and imaging data can be successfully employed to predict suitability for minimally invasive surgery in the majority of patients with single-gland disease.
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Affiliation(s)
- Dara O Kavanagh
- Department of Breast & Endocrine Surgery, St. Vincents University Hospital, Elm Park, Dublin 4, Ireland.
| | - Patricia Fitzpatrick
- Department of Medicine, Physiotherapy & Population Science, School of Public Health Medicine, University College Dublin, Belfield, Dublin 4, Ireland
- School of Medicine & Medical Science, University College Dublin, Belfield, Dublin 4, Ireland
| | - Eddie Myers
- Department of Breast & Endocrine Surgery, St. Vincents University Hospital, Elm Park, Dublin 4, Ireland
| | - Rory Kennelly
- Department of Breast & Endocrine Surgery, St. Vincents University Hospital, Elm Park, Dublin 4, Ireland
| | - Stephen J Skehan
- Department of Radiology, St. Vincents University Hospital, Elm Park, Dublin 4, Ireland
| | - Robert G Gibney
- Department of Radiology, St. Vincents University Hospital, Elm Park, Dublin 4, Ireland
| | - Arnold D K Hill
- Department of Breast & Endocrine Surgery, St. Vincents University Hospital, Elm Park, Dublin 4, Ireland
| | - Denis Evoy
- Department of Breast & Endocrine Surgery, St. Vincents University Hospital, Elm Park, Dublin 4, Ireland
| | - Enda W McDermott
- Department of Breast & Endocrine Surgery, St. Vincents University Hospital, Elm Park, Dublin 4, Ireland
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Jassam N, Gopaul S, McShane P, McHugh A, Coleman R, Thompson D, Barth JH. Calcium adjustment equations in neonates and children. Ann Clin Biochem 2012; 49:352-8. [DOI: 10.1258/acb.2011.011060] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background Calcium exists in human blood in a free form and in a form bound to plasma proteins, principally albumin. Since it is the ionized form that is biologically active, it has long been common practice to present calcium adjusted on the basis of serum albumin concentration. The concept of adjusted calcium has only been evaluated in adults. In this study, we evaluated the use of the adult-adjusted equation to report calcium in children. Methods We searched the laboratory information system over three teaching hospitals for young patients aged between newborn and 18 years old with a request for calcium and albumin analysis but with no evidence of disturbances of calcium homeostasis. These data were organized on the basis of age and was separated into four age groups (birth to 1 month old, 1 month to 1 year old, 1 to 5 years old and 5 to 18 years old). These data were subjected to regression analysis to derive the calcium-adjusted equation for each age group. Results There is an inverse relationship between the bias value and the age. The younger the age, the higher the difference between the adjusted calcium calculated by the adult equation and that calculated by the age-specific equation. This pattern was maintained on all sites. Conclusion For all sites, the adult-adjusted calcium equation may be used to calculate the adjusted calcium for children aged one year old and above.
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Affiliation(s)
| | - Shireen Gopaul
- Department of Paediatrics, Leeds Teaching Hospitals NHS Trust, Leeds LS1 3EX
| | - Philip McShane
- Department of Research & Development, Leeds University, Leeds LS2 9JT, UK
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49
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Kato A, Takita T, Furuhashi M, Fujimoto T, Suzuki H, Hakamada M, Maruyama Y. Influence of the Assay for Measuring Serum Albumin on Corrected Total Calcium in Chronic Hemodialysis Patients. Ther Apher Dial 2011; 15:540-6. [DOI: 10.1111/j.1744-9987.2011.00997.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
BACKGROUND High serum calcium levels have been associated with cognitive decline in older adults. These associations have not been studied in younger adults. The possible association of vitamin D with cognitive function, independent of calcium, is unknown. METHODS A cross-sectional study of associations of serum ionized calcium and 25-hydroxyvitamin D levels with cognitive function in younger adults (20-59 years) and older adults (60-90 years) was conducted using data from the US third National Health and Nutrition Examination Survey (NHANES III). RESULTS Neither serum ionized calcium nor 25-hydroxyvitamin D was associated with cognitive function in either age group. For example, the confounder-adjusted mean difference in reaction time in young adults was 0.00 (95% confidence interval = -0.07 to 0.06) per 1 SD calcium. CONCLUSION Our results do not support an important role for calcium or vitamin D in cognitive performance in adults.
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