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Rostoker G, Dekeyser M, Francisco S, Loridon C, Griuncelli M, Languille-Llitjos E, Boulahia G, Cohen Y. Relationship between bone marrow iron load and liver iron concentration in dialysis-associated haemosiderosis. EBioMedicine 2024; 99:104929. [PMID: 38128412 PMCID: PMC10776950 DOI: 10.1016/j.ebiom.2023.104929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 12/01/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Iron overload due to the excessive use of parenteral iron in haemodialysis is now an increasingly recognised clinical issue. Before erythropoiesis-stimulating agents (ESA) were introduced, a specific feature of patients treated by dialysis and having iron overload was that iron levels in the bone marrow were paradoxically low in most of them, despite severe hepatosplenic siderosis. Whether or not this paradox persists in the actual ESA era was unknown until recently, when an autopsy study in 21 patients treated by haemodialysis revealed similarities between liver and bone marrow iron content. The aim of this study was to further explore these recent findings in a cohort of alive patients on dialysis and to analyse the determinants of iron bone marrow. METHODS Liver iron concentration (LIC) and vertebral T2∗ (a surrogate marker of bone marrow iron) were analysed retrospectively in 152 alive patients on dialysis (38.8% female) of whom 47.4% had iron overload by quantitative magnetic resonance imaging (MRI). FINDINGS Vertebral T2∗ differed significantly between patients classified according to liver iron content at MRI: those with mild or moderate and severe liver iron overload had increased vertebral iron content at R2∗ relaxometry MRI (mild: vertebral T2∗ = 9.9 ms (4-24.8); moderate and severe: vertebral T2∗ = 8.5 ms (4.9-22.8)) when compared to patients with normal LIC (vertebral T2∗ = 13.2 ms (6.6-30.5) (p < 0.0001 Kruskal-Wallis test)). INTERPRETATION The paradoxical discrepancy between bone marrow and liver iron-storage compartments observed in the pre-ESA era has disappeared today, as shown by a recent autopsy study and the present study in a cohort of alive patients treated by dialysis. FUNDING None.
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Affiliation(s)
- Guy Rostoker
- Division of Nephrology and Dialysis, Ramsay Santé, Hôpital Privé Claude Galien, Quincy-sous-Sénart 91480, France; Collège de Médecine des Hôpitaux de Paris, 10 Rue des Fossés Saint-Marcel, Paris 75005, France.
| | - Manon Dekeyser
- Department of Nephrology, Regional University Centre, Orléans and INSERM 1186, Gustave Roussy Institute, Paris-Saclay University, Villejuif, Paris, France
| | - Sergio Francisco
- Division of Radiology, Ramsay Santé, Hôpital Privé Claude Galien, Quincy-sous-Sénart 91480, France
| | - Christelle Loridon
- Division of Nephrology and Dialysis, Ramsay Santé, Hôpital Privé Claude Galien, Quincy-sous-Sénart 91480, France
| | - Mireille Griuncelli
- Division of Nephrology and Dialysis, Ramsay Santé, Hôpital Privé Claude Galien, Quincy-sous-Sénart 91480, France
| | - Eva Languille-Llitjos
- Division of Nephrology and Dialysis, Ramsay Santé, Hôpital Privé Claude Galien, Quincy-sous-Sénart 91480, France
| | - Ghada Boulahia
- Division of Nephrology and Dialysis, Ramsay Santé, Hôpital Privé Claude Galien, Quincy-sous-Sénart 91480, France
| | - Yves Cohen
- Division of Radiology, Ramsay Santé, Hôpital Privé Claude Galien, Quincy-sous-Sénart 91480, France
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Nashwan AJ, Yassin MA, Abd-Alrazaq A, Shuweihdi F, Othman M, Abdul Rahim HF, Shraim M. Hepatic and cardiac iron overload quantified by magnetic resonance imaging in patients on hemodialysis: A systematic review and meta-analysis. Hemodial Int 2023; 27:3-11. [PMID: 36397717 DOI: 10.1111/hdi.13054] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 10/19/2022] [Accepted: 10/26/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Few studies have reported hepatic and cardiac iron overload in patients with end-stage renal disease (ESRD), and the current evidence regarding the prevalence is still scarce. AIM This review aims to estimate the prevalence of hepatic and/or cardiac iron overload quantified by magnetic resonance imaging (MRI) in patients with ESRD who receive hemodialysis (HD), peritoneal dialysis (PD), or have undergone a kidney transplant. METHODS A systematic review with meta-analysis was conducted and reported in line with PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines. MEDLINE and Embase bibliographic databases were searched using a comprehensive list of controlled vocabulary and keywords to identify relevant studies. All studies reporting the prevalence of hepatic and/or cardiac iron overload quantified by MRI in ESRD patients were considered. The Newcastle-Ottawa scale was used to assess the methodological quality of included studies. To investigate the heterogeneity between studies, random-effect meta-analyses for proportions were used. RESULTS The review comprised seven studies that included 339 patients. Using meta-analysis, the pooled prevalence of severe and mild to moderate hepatic iron overload quantified by MRI was 0.23 [95% CI: 0.08-0.43] and 0.52 [95% CI: 0.47-0.57], respectively. Only three studies included cardiac iron quantification, and none reported iron overload. CONCLUSIONS This review has revealed a high prevalence of severe hepatic iron overload in patients with ESRD treated by HD. Further studies with a larger sample size are needed to determine the impact of iron overload on vital organs in patients with ESRD and guide future research in this understudied field. Proper use of iron chelation and continuous monitoring will help in the early detection of unsolicited complications; however, the low renal clearance of most iron chelators limits the options for treating iron excess in patients with ESRD.
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Affiliation(s)
- Abdulqadir J Nashwan
- Department of Nursing, Hazm Mebaireek General Hospital, Hamad Medical Corporation, Doha, Qatar.,Department of Public Health, College of Health Sciences, QU Health, Qatar University, Doha, Qatar
| | - Mohamed A Yassin
- Hematology and Oncology, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Alaa Abd-Alrazaq
- AI Center for Precision Health, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Farag Shuweihdi
- School of Medicine, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Muftah Othman
- Nephrology Section, Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | - Hanan F Abdul Rahim
- Department of Public Health, College of Health Sciences, QU Health, Qatar University, Doha, Qatar
| | - Mujahed Shraim
- Department of Public Health, College of Health Sciences, QU Health, Qatar University, Doha, Qatar
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Chen T, Huang J, Dong H, Xu L, Chen C, Tang Y, Huang W. Efficacy and safety of roxadustat for the treatment of anemia in non-dialysis chronic kidney disease patients: A systematic review and meta-analysis of randomized double-blind controlled clinical trials. Front Nutr 2022; 9:1029432. [PMID: 36466382 PMCID: PMC9710737 DOI: 10.3389/fnut.2022.1029432] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 10/14/2022] [Indexed: 02/02/2024] Open
Abstract
OBJECTIVE To evaluate the efficacy and safety of roxadustat in the treatment of anemia in non-dialysis-dependent chronic kidney disease (NDD-CKD) patients. MATERIALS AND METHODS For this systematic review and meta-analysis, we searched for randomized controlled trials (RCTs) of anemia in NDD-CKD patients to assess the efficacy and safety of roxadustat. The primary efficacy endpoint was the proportion of patients who achieved a hemoglobin (Hb) response. Secondary efficacy endpoints were hepcidin, serum iron, serum ferritin (SF), total iron-binding capacity (TIBC), transferrin saturation (TAST), and low-density lipoprotein (LDL). In addition, adverse events (AEs) were compared. Meta-analyses were performed using Revman 5.4 software. The quality of the evidence was assessed using the Cochrane risk of bias tool. This study was conducted under a pre-established protocol registered with PROSPERO (registration number: CRD42021252331). RESULTS Seven studies enrolled 4,764 patients, of whom 2,730 received roxadustat and 2,034 received placebo. The results of this meta-analysis showed that roxadustat increased Hb levels [weighted mean difference (WMD) = 1.43, 95% CI: 1.17 to 1.68, P < 0.001, I 2 = 95%], and Hb response [relative ratio (RR) = 8.12, 95% CI: 5.80 to 11.37, P < 0.001, I 2 = 61%]. In addition, roxadustat significantly increased transferrin TAST. During the treatment period in patients with anemia, the AEs of roxadustat compared with placebo was not statistically significant. CONCLUSION Roxadustat can improve anemia in NDD-CKD patients by increasing Hb levels and regulating iron metabolism, but does not increase the incidence of AEs. SYSTEMATIC REVIEW REGISTRATION [https://www.crd.york.ac.uk/prospero/], identifier [CRD42021252331].
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Affiliation(s)
- Ting Chen
- The First Clinical Medical College, Gansu University of Traditional Chinese Medicine, Lanzhou, China
- Department of Nephrology, Gansu Provincial Hospital, Lanzhou, China
| | - Junyue Huang
- Department of Nephrology, Gansu Provincial Hospital, Lanzhou, China
| | - Hui Dong
- Department of Nephrology, Gansu Provincial Hospital, Lanzhou, China
| | - Lili Xu
- The First Clinical Medical College, Gansu University of Traditional Chinese Medicine, Lanzhou, China
- Department of Nephrology, Gansu Provincial Hospital, Lanzhou, China
| | - Caihe Chen
- The First Clinical Medical College, Gansu University of Traditional Chinese Medicine, Lanzhou, China
- Department of Nephrology, Gansu Provincial Hospital, Lanzhou, China
| | - Yu Tang
- Clinical Lab, Gansu Provincial Hospital, Lanzhou, China
| | - Wenhui Huang
- Department of Nephrology, Gansu Provincial Hospital, Lanzhou, China
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Rostoker G, Lepeytre F, Merzoug M, Griuncelli M, Loridon C, Boulahia G, Cohen Y. Differential Pharmacokinetics of Liver Tropism for Iron Sucrose, Ferric Carboxymaltose, and Iron Isomaltoside: A Clue to Their Safety for Dialysis Patients. Pharmaceutics 2022; 14:pharmaceutics14071408. [PMID: 35890303 PMCID: PMC9323124 DOI: 10.3390/pharmaceutics14071408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/29/2022] [Accepted: 07/02/2022] [Indexed: 01/31/2023] Open
Abstract
Anemia is a major complication of end-stage kidney disease (ESKD). Erythropoiesis-stimulating agents and intravenous (IV) iron are the current backbone of anemia treatment in ESKD. Iron overload induced by IV iron is a potential clinical problem in dialysis patients. We compared the pharmacokinetics of liver accumulation of iron sucrose, currently used worldwide, with two third-generation IV irons (ferric carboxymaltose and iron isomaltoside). We hypothesized that better pharmacokinetics of newer irons could improve the safety of anemia management in ESKD. Liver iron concentration (LIC) was analyzed in 54 dialysis patients by magnetic resonance imaging under different modalities of iron therapy. LIC increased significantly in patients treated with 1.2 g or 2.4 g IV iron sucrose (p < 0.001, Wilcoxon test), whereas no significant increase was observed in patients treated with ferric carboxymaltose or iron isomaltoside (p > 0.05, Wilcoxon-test). Absolute differences in LIC reached 25 μmol/g in the 1.2 g iron sucrose group compared with only 5 μmol/g in the 1 g ferric carboxymaltose and 1 g iron isomaltoside groups (p < 0.0001, Kruskal−Wallis test). These results suggest the beneficial consequences of using ferric carboxymaltose or iron isomaltoside on liver structure in ESKD due to their pharmacokinetic ability to minimize iron overload.
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Affiliation(s)
- Guy Rostoker
- Division of Nephrology and Dialysis, Ramsay Santé, Hôpital Privé Claude Galien, 91480 Quincy-Sous-Sénart, France; (F.L.); (M.M.); (M.G.); (C.L.); (G.B.)
- Collége de Médecine des Hôpitaux de Paris, 75005 Paris, France
- Correspondence: ; Tel.: +33-1-69-39-92-00
| | - Fanny Lepeytre
- Division of Nephrology and Dialysis, Ramsay Santé, Hôpital Privé Claude Galien, 91480 Quincy-Sous-Sénart, France; (F.L.); (M.M.); (M.G.); (C.L.); (G.B.)
| | - Myriam Merzoug
- Division of Nephrology and Dialysis, Ramsay Santé, Hôpital Privé Claude Galien, 91480 Quincy-Sous-Sénart, France; (F.L.); (M.M.); (M.G.); (C.L.); (G.B.)
| | - Mireille Griuncelli
- Division of Nephrology and Dialysis, Ramsay Santé, Hôpital Privé Claude Galien, 91480 Quincy-Sous-Sénart, France; (F.L.); (M.M.); (M.G.); (C.L.); (G.B.)
| | - Christelle Loridon
- Division of Nephrology and Dialysis, Ramsay Santé, Hôpital Privé Claude Galien, 91480 Quincy-Sous-Sénart, France; (F.L.); (M.M.); (M.G.); (C.L.); (G.B.)
| | - Ghada Boulahia
- Division of Nephrology and Dialysis, Ramsay Santé, Hôpital Privé Claude Galien, 91480 Quincy-Sous-Sénart, France; (F.L.); (M.M.); (M.G.); (C.L.); (G.B.)
| | - Yves Cohen
- Division of Radiology, Ramsay Santé, Hôpital Privé Claude Galien, 91480 Quincy-Sous-Sénart, France;
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Hanafusa N, Tu C, McCullough K, Bieber B, Pisoni RL, Robinson BM, Hasegawa T, Nangaku M. An Investigation into Possible Sex Differences in Association of Hemoglobin with Survival Among Hemodialysis Patients in the J-DOPPS Cohort. Nephrology (Carlton) 2022; 27:795-803. [PMID: 35442547 DOI: 10.1111/nep.14046] [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: 01/06/2022] [Revised: 04/14/2022] [Accepted: 04/16/2022] [Indexed: 11/30/2022]
Abstract
AIMS Lower hemoglobin levels are common among females without kidney diseases. However, little is known about the sex-specific management of anemia in hemodialysis patients. METHODS This prospective cohort study investigated the role of sex differences in the association between categorical baseline or time-varying hemoglobin levels and all-cause mortality via cox regression using data from 6890 patients the Japan Dialysis Outcomes and Practice Patterns Study (J-DOPPS, 2005-2015). Likelihood ratio tests were used to evaluate the effect modification of sex on the relationship between hemoglobin and mortality. RESULTS A total of 781 patients died during the median follow-up of 31 months. Mortality risk, adjusted for case mix, varied between five hemoglobin categories, with the highest category (≥12 g/dl) having a hazard ratio of 0.73 (0.41-1.29) for females and 2.02 (1.03-3.95) for males versus 10-10.9 g/dl. Despite this difference, the p-value comparing the overall among males versus females was.35. Similar associations were observed in models stratified by patient age (<75 years), time on dialysis (≤1 year), and models lagging the hemoglobin exposure. CONCLUSIONS The results based on this sample of Japanese hemodialysis patients did not support the hypothesis that the association between hemoglobin and survival differed by sex. We also could not conclude that the association was identical, as the parameter estimates are consistent with male patients having a relatively greater mortality risk than female patients at higher hemoglobin levels. More detailed investigations into the effects of higher hemoglobin levels by sex might help better understand strategies for anemia management.
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Affiliation(s)
- Norio Hanafusa
- Department of Blood Purification, Tokyo Women's Medical University, Tokyo, Japan
| | - Charlotte Tu
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | - Brian Bieber
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | | | - Takeshi Hasegawa
- Showa University Research Administraiton Center, Tokyo.,Division of Nephrology, Department of Medicine, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo School of Medicine, Tokyo, Japan
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6
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Weir MR. Managing Anemia across the Stages of Kidney Disease in Those Hyporesponsive to Erythropoiesis-Stimulating Agents. Am J Nephrol 2021; 52:450-466. [PMID: 34280923 DOI: 10.1159/000516901] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/26/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with CKD frequently have anemia that results from iron-restricted erythropoiesis and inflammation. Anemia of CKD is currently managed with iron supplements and erythropoiesis-stimulating agents (ESAs) to promote erythropoiesis and with RBC transfusion in severe cases. Hyporesponse to ESAs, or the need for larger than usual doses to attain a given hemoglobin (Hb) level, is associated with increased morbidity and mortality and presents a pressing clinical challenge, particularly for patients on dialysis. This paper reviews ESA hyporesponse and potential new therapeutic options in the management of anemia of CKD. SUMMARY The most common causes of ESA hyporesponse include iron deficiency and inflammation, and to a lesser degree, secondary hyperparathyroidism, inadequate dialysis, malnutrition, and concomitant medications. Management of ESA hyporesponse is multipronged and involves treating low level infections, ensuring adequate nutrition, and optimizing iron status and dialysis modality, although some patients can remain refractory. Inflammation directly increases production and secretion of hepcidin, contributes to an impaired response to hypoxia, and suppresses proliferation of erythroid progenitors. Coordination of renal and hepatic erythropoietin (EPO) production and iron metabolism is under the control of hypoxia-inducible factors (HIF), which are in turn regulated by HIF-prolyl hydroxylases (HIF-PHs). HIF-PHs and hepcidin are therefore attractive potential drug targets particularly in patients with ESA hyporesponse. Several oral HIF-PH inhibitors have been evaluated in patients with anemia of CKD and have been shown to increase Hb and reduce hepcidin regardless of inflammation, iron status, or dialysis modality. These sustained effects are achieved through more modest increases in endogenous EPO compared with ESAs. Key Messages: Treatments that address ESA hyporesponse remain a significant unmet clinical need in patients with anemia of CKD. New therapies such as HIF-PH inhibitors have the potential to address fundamental aspects of ESA hyporesponse and provide a new therapeutic option in these patients.
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Affiliation(s)
- Matthew R Weir
- Division of Nephrology, University of Maryland Medical Center, Baltimore, Maryland, USA
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7
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Afsar RE, Kanbay M, Ibis A, Afsar B. In-depth review: is hepcidin a marker for the heart and the kidney? Mol Cell Biochem 2021; 476:3365-3381. [PMID: 33942218 DOI: 10.1007/s11010-021-04168-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 04/21/2021] [Indexed: 12/15/2022]
Abstract
Iron is an essential trace element involved in oxidation-reduction reactions, oxygen transport and storage, and energy metabolism. Iron in excess can be toxic for cells, since iron produces reactive oxygen species and is important for survival of pathogenic microbes. There is a fine-tuning in the regulation of serum iron levels, determined by intestinal absorption, macrophage iron recycling, and mobilization of hepatocyte stores versus iron utilization, primarily by erythroid cells in the bone marrow. Hepcidin is the major regulatory hormone of systemic iron homeostasis and is upregulated during inflammation. Hepcidin metabolism is altered in chronic kidney disease. Ferroportin is an iron export protein and mediates iron release into the circulation from duodenal enterocytes, splenic reticuloendothelial macrophages, and hepatocytes. Systemic iron homeostasis is controlled by the hepcidin-ferroportin axis at the sites of iron entry into the circulation. Hepcidin binds to ferroportin, induces its internalization and intracellular degradation, and thus inhibits iron absorption from enterocytes, and iron release from macrophages and hepatocytes. Recent data suggest that hepcidin, by slowing or preventing the mobilization of iron from macrophages, may promote atherosclerosis and may be associated with increased cardiovascular disease risk. This article reviews the current data regarding the molecular and cellular pathways of systemic and autocrine hepcidin production and seeks the answer to the question whether changes in hepcidin translate into clinical outcomes of all-cause and cardiovascular mortality, and cardiovascular and renal end-points.
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Affiliation(s)
- Rengin Elsurer Afsar
- Department of Nephrology, Faculty of Medicine, Suleyman Demirel University, Isparta, Turkey.
| | - Mehmet Kanbay
- Department of Nephrology, Faculty of Medicine, Koc University, Istanbul, Turkey
| | - Avsin Ibis
- Department of Nephrology, Afyon Kocatepe Devlet Hastanesi, Afyon, Turkey
| | - Baris Afsar
- Department of Nephrology, Faculty of Medicine, Suleyman Demirel University, Isparta, Turkey
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8
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Xu Y, Wang Y, Hu H, Li J, Tian T. Relationship between serum hepcidin levels and cardiovascular disease in patients with maintenance hemodialysis. Physiol Int 2020; 107:491-500. [PMID: 33355540 DOI: 10.1556/2060.2020.00040] [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: 03/26/2020] [Accepted: 07/06/2020] [Indexed: 11/19/2022]
Abstract
Background To investigate the serum level of hepcidin and its relationship with cardiovascular disease (CVD) in maintenance hemodialysis (MHD) patients. Methods Blood was obtained from 75 MHD patients before undergoing hemodialysis and 20 healthy controls. Serum hepcidin, advanced oxidation protein products (AOPP) and interleukin (IL)-6 were measured by enzyme-linked immunosorbant assay (ELISA). Spearman correlation, and binary logistic regression linear regression analyses were used to assess the relationship between serum hepcidin and other parameters. Results The serum level of hepcidin, AOPP and IL-6 was significantly up-regulated in MHD patients compared with the control (P < 0.05). Furthermore, serum hepcidin levels in patients with CVD were higher than those in patients without CVD (P < 0.05). In all MHD patients, serum hepcidin level was correlated positively with erythropoietin (EPO) dose per week (ρ = 0.251, P = 0.030), EPO resistance index (ρ = 0.268, P = 0.020), ferritin (ρ = 0.814, P < 0.001), transferin saturation (TSAT, ρ = 0.263, P = 0.023), AOPP (ρ = 0.280, P = 0.049), high sensitive C reactive protein (ρ = 0.151, P = 0.006), IL-6 (ρ = 0.340, P = 0.003) and left ventricular mass index (LVMI, ρ = 0.290, P = 0.033). Moreover, it was negatively correlated with serum pre-albumin (ρ = -0.266, P = 0.021), total iron-binding capacity (TIBC, ρ = -0.458, P < 0.001), unsaturated iron-binding capacity (UIBC, ρ = -0.473, P < 0.001) and transferrin (ρ = -0.487, P < 0.001). Linear regression analysis showed that ferritin (β = 0.708, P < 0.001), TIBC (β = -0.246, P = 0.032) and IL-6 (β = 0.209, P = 0.041) were independently associated with hepcidin. Results of binary logistic regression analysis suggested that higher serum hepcidin level (>249.2 ng/mL) was positively and independently related to CVD (OR = 1.32, 95% CI [1.20-9.56], P = 0.043). Conclusions Serum hepcidin level is associated with CVD in MHD patients, indicating that hepcidin may be a novel biomarker and therapeutic target for CVD.
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Affiliation(s)
- Y Xu
- 1Hemodialysis Center, Shanghai Yangsi Hospital, Pudong New Area, Shanghai, China
| | - Y Wang
- 2Hemodialysis Center, Yantai Affiliated Hospital of Binzhou Medical University, Yantai City, Shandong Province, China
| | - H Hu
- 1Hemodialysis Center, Shanghai Yangsi Hospital, Pudong New Area, Shanghai, China
| | - J Li
- 1Hemodialysis Center, Shanghai Yangsi Hospital, Pudong New Area, Shanghai, China
| | - T Tian
- 1Hemodialysis Center, Shanghai Yangsi Hospital, Pudong New Area, Shanghai, China
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9
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Del Vecchio L, Ekart R, Ferro CJ, Malyszko J, Mark PB, Ortiz A, Sarafidis P, Valdivielso JM, Mallamaci F. Intravenous iron therapy and the cardiovascular system: risks and benefits. Clin Kidney J 2020; 14:1067-1076. [PMID: 34188903 PMCID: PMC8223589 DOI: 10.1093/ckj/sfaa212] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 08/31/2020] [Indexed: 12/12/2022] Open
Abstract
Anaemia is a common complication of chronic kidney disease (CKD). In this setting, iron deficiency is frequent because of the combination of increased iron needs to sustain erythropoiesis with increased iron losses. Over the years, evidence has accumulated on the involvement of iron in influencing pulmonary vascular resistance, endothelial function, atherosclerosis progression and infection risk. For decades, iron therapy has been the mainstay of therapy for renal anaemia together with erythropoiesis-stimulating agents (ESAs). Despite its long-standing use, grey areas still surround the use of iron therapy in CKD. In particular, the right balance between either iron repletion with adequate therapy and the avoidance of iron overload and its possible negative effects is still a matter of debate. This is particularly true in patients having functional iron deficiency. The recent Proactive IV Iron Therapy in Haemodialysis Patients trial supports the use of intravenous (IV) iron therapy until a ferritin upper limit of 700 ng/mL is reached in haemodialysis patients on ESA therapy, with short dialysis vintage and minimal signs of inflammation. IV iron therapy has also been proven to be effective in the setting of heart failure (HF), where it improves exercise capacity and quality of life and possibly reduces the risk of HF hospitalizations and cardiovascular deaths. In this review we discuss the risks of functional iron deficiency and the possible benefits and risks of iron therapy for the cardiovascular system in the light of old and new evidence.
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Affiliation(s)
- Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant'Anna Hospital, ASST Lariana, Como, Italy
| | - Robert Ekart
- Department of Dialysis, Clinic for Internal Medicine, University Clinical Center Maribor, Maribor, Slovenia
| | - Charles J Ferro
- Renal Unit, University Hospitals Birmingham and Institute of Cardiovascular Science, University of Birmingham, Birmingham, UK
| | - Jolanta Malyszko
- Department of Nephrology, Dialysis and Internal Disease, Medical University of Warsaw, Warsaw, Poland
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Alberto Ortiz
- Department of Nephrology and Hypertension, IIS-Fundacion Jimenez Diaz, Universidad Autonoma de Madrid, Madrid, Spain
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Jose M Valdivielso
- Vascular and Renal Translational Research Group and UDETMA, Institut de Recerca Biomèdica de Lleida, Lleida, Spain
| | - Francesca Mallamaci
- CNR-IFC Clinical Epidemiology of Renal Diseases and Hypertension, Reggio Calabria, Italy
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10
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Relation of serum hepcidin levels and restless legs syndrome in chronic hemodialysis patients. Sleep Breath 2020; 25:897-905. [PMID: 33029690 DOI: 10.1007/s11325-020-02209-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/21/2020] [Accepted: 09/12/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Iron deficiency anemia, pregnancy, and end-stage renal disease (ESRD) are common causes of secondary restless legs syndrome (RLS). Serum ferritin is considered the most specific test associated with the total amount of body iron stores. However, due to the increase of serum ferritin secondary to inflammation in chronic hemodialysis (HD) patients, serum ferritin test results do not fully reflect decreased iron stores in these patients. The present study evaluates the serum hepcidin levels, as the main regulator of iron metabolism, and its relationship with RLS in chronic HD patients. METHODS The present cross-sectional study involved 72 patients (36 with and 36 without RLS) who received chronic HD treatment between April 2014 and April 2015. Demographic and biochemical data were evaluated in all patients, and statistical analyses were performed. RESULTS The mean age and mean dialysis vintage of all patients (56% women) included in the study were 65.3 ± 11.6 years and 41.5 ± 36.5 months, respectively. Serum hepcidin, hemoglobin A1C (HbA1C), and ferritin levels were significantly higher in patients with RLS (p = 0.001, p = 0.032, p = 0.042, respectively). In addition, a positive correlation was found between International Restless Legs Syndrome Study Group severity scale score and serum hepcidin levels, HbA1C, and ferritin (r = 0.387, p = 0.001; r = 0.426, p = 0.034; r = 0.240, p = 0.046, respectively). A multivariate linear regression analysis revealed hepcidin and HbA1C to be independently associated with the presence of RLS. CONCLUSION A significant relationship was detected between RLS and increased serum hepcidin levels in chronic HD patients, and uncontrolled diabetes was noted to contribute to this association.
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Kuragano T, Joki N, Hase H, Kitamura K, Murata T, Fujimoto S, Fukatsu A, Inoue T, Itakura Y, Nakanishi T. Low transferrin saturation (TSAT) and high ferritin levels are significant predictors for cerebrovascular and cardiovascular disease and death in maintenance hemodialysis patients. PLoS One 2020; 15:e0236277. [PMID: 32877424 PMCID: PMC7467218 DOI: 10.1371/journal.pone.0236277] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 07/01/2020] [Indexed: 12/17/2022] Open
Abstract
Patients with high serum ferritin and low transferrin saturation (TSAT) levels could be considered as presenting with dysutilization of iron for erythropoiesis. However, the long-term safety of iron administration in these patients has not been well established. An observational multicenter study was performed over 3 years. In 805 patients undergoing maintenance hemodialysis (MHD), we defined dysutilization of iron for erythropoiesis in patients with lower TSAT (<20%) and higher ferritin (≥100 ng/mL) levels. A time-dependent Cox hazard model was used for the evaluation of the association between dysutilization of iron for erythropoiesis and adverse events and survival. Patients with low TSAT levels showed an increased risk of cerebrovascular and cardiovascular disease (CCVD) and death compared to patients with normal or higher TSAT levels. Patients with low ferritin and high TSAT levels had a significantly lower risk of CCVD and death compared with patients with high ferritin and low TSAT levels. Higher TSAT levels were associated with male gender, age, the absence of diabetes, low levels of high-sensitivity CRP, and low β2 microglobulin levels, but not with intravenous iron administration or ferritin levels. Although patients with low TSAT levels had a significantly higher risk of CCVD or death, high TSAT levels were not linked with iron administration. Patients, who were suspected of dysutilization of iron for erythropoiesis, had a higher risk of CCVD and death. The administration of iron should be performed cautiously for improving TSAT levels, as iron administration could sustain TSAT levels for a short term.
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Affiliation(s)
- Takahiro Kuragano
- Department of Internal Medicine, Division of Kidney and Dialysis, Hyogo College of Medicine, Nisinomiya, Japan
- * E-mail:
| | - Nobuhiko Joki
- Department of Nephrology, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Hiroki Hase
- Department of Nephrology, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Kenichiro Kitamura
- The Third Department of Internal Medicine Faculty of Medicine, The University of Yamanashi, Yamanashi, Japan
| | - Toshiaki Murata
- Department of Nephrology, Murakami karin dou Hospital, Fukuoka, Japan
| | - Shouichi Fujimoto
- Department of Hemovascular Medicine and Artificial Organs, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Atushi Fukatsu
- Department of Nephrology, Hekinan Municipal Hospital, Hekinan, Japan
| | - Toru Inoue
- Department of Internal Medicine, Yuseikai Clinic, Osaka, Japan
| | | | - Takeshi Nakanishi
- Department of Internal Medicine, Division of Kidney and Dialysis, Hyogo College of Medicine, Nisinomiya, Japan
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Ghafourian K, Shapiro JS, Goodman L, Ardehali H. Iron and Heart Failure: Diagnosis, Therapies, and Future Directions. JACC Basic Transl Sci 2020; 5:300-313. [PMID: 32215351 PMCID: PMC7091506 DOI: 10.1016/j.jacbts.2019.08.009] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 08/29/2019] [Accepted: 08/29/2019] [Indexed: 12/11/2022]
Abstract
To date, 3 clinical trials have shown symptomatic benefit from the use of intravenous (IV) iron in patients with heart failure (HF) with low serum iron. This has led to recommendations in support of the use of IV iron in this population. However, the systemic and cellular mechanisms of iron homeostasis in cardiomyocyte health and disease are distinct, complex, and poorly understood. Iron metabolism in HF appears dysregulated, but it is still unclear whether the changes are maladaptive and pathologic or compensatory and protective for the cardiomyocytes. The serum markers of iron deficiency in HF do not accurately reflect cellular and mitochondrial iron levels, and the current definition based on the ferritin and transferrin saturation values is broad and inclusive of patients who do not need IV iron. This is particularly relevant in view of the potential risks that are associated with the use of IV iron. Reliable markers of cellular iron status may differentiate subgroups of HF patients who would benefit from cellular and mitochondrial iron chelation rather than IV iron.
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Key Words
- 6MWT, 6-min walk test
- CKD, chronic kidney disease
- DMT1, divalent metal transporter 1 protein
- FCM, ferric carboxymaltose
- FGF, fibroblast growth factor
- Fpn1, ferroportin 1
- Hb, hemoglobin
- I/R, ischemia/reperfusion
- ID, iron deficiency
- IV, intravenous
- LVEF, left ventricular ejection fraction
- NTBI, non–transferrin-bound iron
- NYHA, New York Heart Association
- PGA, Patient Global Assessment
- RCT, randomized clinical trial
- ROS, reactive oxygen species
- TSAT, transferrin saturation
- TfR1, transferrin receptor protein 1
- VO2, peak oxygen uptake
- heart failure
- intravenous iron
- iron chelation
- iron deficiency
- sTfR, soluble transferrin receptor
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Affiliation(s)
| | | | | | - Hossein Ardehali
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University, Chicago, Illinois
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13
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The role of hepcidin and iron homeostasis in atherosclerosis. Pharmacol Res 2020; 153:104664. [PMID: 31991168 DOI: 10.1016/j.phrs.2020.104664] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 12/20/2019] [Accepted: 01/24/2020] [Indexed: 02/06/2023]
Abstract
Atherosclerotic cardiovascular disease is a major burden on global health and a leading cause of death worldwide. The pathophysiology of this chronic disease is complex, involving inflammation, lipoprotein oxidation and accumulation, plaque formation, and calcification. In 1981, Dr. Jerome Sullivan formulated the 'Iron Hypothesis', suggesting that higher levels of stored iron promote cardiovascular diseases, whereas iron deficiency may have an atheroprotective effect. This hypothesis has stimulated research focused on clarifying the role of iron in the development of atherosclerosis. However, preclinical and clinical studies have produced contradictory results and the observation that patients with hemochromatosis do not appear to have an increased risk of atherosclerosis seemed incongruous with Sullivan's initial hypothesis. The 'paradox' of systemic iron overload not being accompanied by an increased risk for atherosclerosis led to a refinement of the iron hypothesis focusing on intracellular macrophage iron. More recent in vitro and animal studies have elucidated the complex signaling pathways regulating iron, with a particular focus on hepcidin, the master regulator of body iron homeostasis. Bone morphogenetic protein (BMP) signaling is the major pathway that is required for induction of hepcidin expression in response to increasing levels of iron. Strong links between iron homeostasis, BMP signaling, inflammation and atherosclerosis have been established in both mechanistic and human studies. This review summarizes the current understanding of the role of iron homeostasis and hepcidin in the development of atherosclerosis and discusses the BMP-hepcidin-ferroportin axis as a novel therapeutic target for the treatment of cardiovascular disease.
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Histological Scores Validate the Accuracy of Hepatic Iron Load Measured by Signal Intensity Ratio and R2* Relaxometry MRI in Dialysis Patients. J Clin Med 2019; 9:jcm9010017. [PMID: 31861625 PMCID: PMC7019535 DOI: 10.3390/jcm9010017] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 12/14/2019] [Accepted: 12/17/2019] [Indexed: 01/02/2023] Open
Abstract
Almost all haemodialysis patients are treated with parenteral iron to compensate for blood loss and to allow the full therapeutic effect of erythropoiesis-stimulating agents. Iron overload is an increasingly recognised clinical situation diagnosed by quantitative magnetic resonance imaging (MRI). MRI methods have not been fully validated in dialysis patients. We compared Deugnier’s and Turlin’s histological scoring of iron overload and Scheuer’s classification (with Perls’ stain) with three quantitative MRI methods for measuring liver iron concentration (LIC)—signal intensity ratio (SIR), R2* relaxometry, and R2* multi-peak spectral modelling (Iterative Decomposition of water and fat with Echo Asymmetry and Least-squares estimation (IDEAL-IQ®)) relaxometry—in 16 haemodialysis patients in whom a liver biopsy was formally indicated for medical follow-up. LIC MRI with these three different methods was highly correlated with Deugnier’s and Turlin’s histological scoring (SIR: r = 0.8329, p = 0.0002; R2* relaxometry: r = −0.9099, p < 0.0001; R2* relaxometry (IDEAL-IQ®): r = −0.872, p = 0.0018). Scheuer’s classification was also significantly correlated with these three MRI techniques. The positive likelihood ratio for the diagnosis of abnormal LIC by Deugnier’s histological scoring was > 62 for the three MRI methods. This study supports the accuracy of quantitative MRI methods for the non-invasive diagnosis and follow-up of iron overload in haemodialysis patients.
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15
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Abstract
Iron is an essential element that is indispensable for life. The delicate physiological body iron balance is maintained by both systemic and cellular regulatory mechanisms. The iron-regulatory hormone hepcidin assures maintenance of adequate systemic iron levels and is regulated by circulating and stored iron levels, inflammation and erythropoiesis. The kidney has an important role in preventing iron loss from the body by means of reabsorption. Cellular iron levels are dependent on iron import, storage, utilization and export, which are mainly regulated by the iron response element-iron regulatory protein (IRE-IRP) system. In the kidney, iron transport mechanisms independent of the IRE-IRP system have been identified, suggesting additional mechanisms for iron handling in this organ. Yet, knowledge gaps on renal iron handling remain in terms of redundancy in transport mechanisms, the roles of the different tubular segments and related regulatory processes. Disturbances in cellular and systemic iron balance are recognized as causes and consequences of kidney injury. Consequently, iron metabolism has become a focus for novel therapeutic interventions for acute kidney injury and chronic kidney disease, which has fuelled interest in the molecular mechanisms of renal iron handling and renal injury, as well as the complex dynamics between systemic and local cellular iron regulation.
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Rostoker G, Vaziri ND. Risk of iron overload with chronic indiscriminate use of intravenous iron products in ESRD and IBD populations. Heliyon 2019; 5:e02045. [PMID: 31338466 PMCID: PMC6627982 DOI: 10.1016/j.heliyon.2019.e02045] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 03/14/2019] [Accepted: 07/03/2019] [Indexed: 01/19/2023] Open
Abstract
The routine use of recombinant erythropoiesis-stimulating agents (ESA) over the past three decades has enabled the partial correction of anaemia in most patients with end-stage renal disease (ESRD). Since ESA use frequently leads to iron deficiency, almost all ESA-treated haemodialysis patients worldwide receive intravenous iron (IV) to ensure sufficient available iron during ESA therapy. Patients with inflammatory bowel disease (IBD) are also often treated with IV iron preparations, as anaemia is common in IBD. Over the past few years, liver magnetic resonance imaging (MRI) has become the gold standard method for non-invasive diagnosis and follow-up of iron overload diseases. Studies using MRI to quantify liver iron concentration in ESRD have shown a link between high infused iron dose and risk of haemosiderosis in dialysis patients. In September 2017, the Pharmacovigilance Committee (PRAC) of the European Medicines Agency (EMA) considered convergent publications over the last few years on iatrogenic haemosiderosis in dialysis patients and requested that companies holding marketing authorization for iron products should investigate the risk of iron overload, particularly in patients with end-stage renal disease on dialysis and, by analogy, patients with IBD. We present a narrative review of data supporting the views and decision of the EMA, and then give our expert opinion on this controversial field of anaemia therapeutics.
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Affiliation(s)
- Guy Rostoker
- Division of Nephrology and Dialysis, Hôpital Privé Claude Galien, Ramsay-Générale de Santé, Quincy-sous-Sénart, France
| | - Nosratola D Vaziri
- Division of Nephrology and Hypertension, University of California, Irvine, USA
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Serum Erythroferrone Levels Associate with Mortality and Cardiovascular Events in Hemodialysis and in CKD Patients: A Two Cohorts Study. J Clin Med 2019; 8:jcm8040523. [PMID: 30995819 PMCID: PMC6518296 DOI: 10.3390/jcm8040523] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/05/2019] [Accepted: 04/05/2019] [Indexed: 02/07/2023] Open
Abstract
Erythroferrone (ERFE) is a hepcidin inhibitor whose synthesis is stimulated by erythropoietin, which increases iron absorption and mobilization. We studied the association between serum ERFE and mortality and non-fatal cardiovascular (CV) events in a cohort of 1123 hemodialysis patients and in a cohort of 745 stage 1–5 chronic kidney disease (CKD) patients. Erythroferrone was measured by a validated enzyme-linked immunosorbent assay (ELISA). In the hemodialysis cohort, serum ERFE associated directly with erythropoiesis stimulating agents (ESA) dose (p < 0.001) and inversely with serum iron and ferritin (p < 0.001). Erythroferrone associated with the combined outcome in an analysis adjusting for traditional risk factors, factors peculiar to end-stage kidney disease, serum ferritin, inflammation, and nutritional status (HR, hazard ratio, (5 ng/mL increase: 1.04, 95% confidence interval, CI: 1.01–1.08, p = 0.005). Furthermore, treatment with ESA modified the relationship between ERFE and the combined end-point in adjusted analyses (p for the effect modification = 0.018). Similarly, in CKD patients there was a linear increase in the risk for the same outcome in adjusted analyses (HR (2 ng/mL increase): 1.04, 95% CI: 1.0–1.07, p = 0.015). Serum ERFE is associated with mortality and CV events in CKD and in HD patients, and treatment by ESA amplifies the risk for this combined end-point in HD patients.
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18
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Sheetz M, Barrington P, Callies S, Berg PH, McColm J, Marbury T, Decker B, Dyas GL, Truhlar SME, Benschop R, Leung D, Berg J, Witcher DR. Targeting the hepcidin-ferroportin pathway in anaemia of chronic kidney disease. Br J Clin Pharmacol 2019; 85:935-948. [PMID: 30677788 DOI: 10.1111/bcp.13877] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 01/04/2019] [Accepted: 01/13/2019] [Indexed: 12/15/2022] Open
Abstract
AIMS Erythropoiesis-stimulating agents used to treat anaemia in patients with chronic kidney disease (CKD) have been associated with cardiovascular adverse events. Hepcidin production, controlled by bone morphogenic protein 6 (BMP6), regulates iron homeostasis via interactions with the iron transporter, ferroportin. High hepcidin levels are thought to contribute to increased iron sequestration and subsequent anaemia in CKD patients. To investigate alternative therapies to erythropoiesis-stimulating agents for CKD patients, monoclonal antibodies, LY3113593 and LY2928057, targeting BMP6 and ferroportin respectively, were tested in CKD patients. METHODS Preclinical in vitro/vivo data and clinical data in healthy subjects and CKD patients were used to illustrate the translation of pharmacological properties of LY3113593 and LY2928057, highlighting the novelty of targeting these nodes within the hepcidin-ferroportin pathway. RESULTS LY2928057 bound ferroportin and blocked interactions with hepcidin, allowing iron efflux, leading to increased serum iron and transferrin saturation levels and increased hepcidin in monkeys and humans. In CKD patients, LY2928057 led to slower haemoglobin decline and reduction in ferritin (compared to placebo). Serum iron increase was (mean [90% confidence interval]) 1.98 [1.46-2.68] and 1.36 [1.22-1.51] fold-relative to baseline following LY2928057 600 mg and LY311593 150 mg respectively in CKD patients. LY3113593 specifically blocked BMP6 binding to its receptor and produced increases in iron and transferrin saturation and decreases in hepcidin preclinically and clinically. In CKD patients, LY3113593 produced an increase in haemoglobin and reduction in ferritin (compared to placebo). CONCLUSION LY3113593 and LY2928057 pharmacological effects (serum iron and ferritin) were translated from preclinical-to-clinical development. Such interventions may lead to new CKD anaemia treatments.
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Affiliation(s)
| | | | | | - Paul H Berg
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | | | | | - Brian Decker
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | | | | | | | - Jolene Berg
- DaVita Clinical Research, Minneapolis, Minnesota, USA
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19
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Vela D. Systemic and local hepcidin as emerging and important peptides in renal homeostasis and pathology. Biofactors 2019; 45:118-134. [PMID: 30461080 DOI: 10.1002/biof.1468] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 09/20/2018] [Accepted: 09/26/2018] [Indexed: 12/14/2022]
Abstract
Recent data suggest that the importance of hepcidin goes beyond its classical role in controlling systemic iron metabolism. Local hepcidins are emerging as important peptides for organ homeostasis in the brain, heart, blood vessels, and in cancer as well. Similarly, accumulating data indicate that hepcidin does seem to be an important factor in renal homeostasis. This review encompasses present knowledge concerning the role of hepcidin in renoprotection and its use as a biomarker of kidney diseases. Understanding the role of hepcidin in kidneys is important due to its relevance for kidney physiology and its potential therapeutic application in kidney pathologies. © 2018 BioFactors, 45(2):118-134, 2019.
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Affiliation(s)
- Driton Vela
- Department of Physiology, Faculty of Medicine, University of Prishtina, Prishtina, Kosova
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20
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Rostoker G, Loridon C, Griuncelli M, Rabaté C, Lepeytre F, Ureña-Torres P, Issad B, Ghali N, Cohen Y. Liver Iron Load Influences Hepatic Fat Fraction in End-Stage Renal Disease Patients on Dialysis: A Proof of Concept Study. EBioMedicine 2018; 39:461-471. [PMID: 30502056 PMCID: PMC6354439 DOI: 10.1016/j.ebiom.2018.11.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 11/08/2018] [Accepted: 11/12/2018] [Indexed: 12/13/2022] Open
Abstract
Background Nonalcoholic fatty liver disease (NAFLD) is a spectrum of diseases including steatosis, nonalcoholic steatohepatitis (NASH), cirrhosis, and end-stage liver failure. Hepatic iron accumulation has been linked to hepatic fibrosis severity in NASH and NAFLD. Iron overload induced by parenteral (IV) iron therapy is a potential clinical problem in dialysis patients. We analyzed the hypothetical triggering and aggravating role of iron on NAFLD in patients on dialysis. Methods Liver iron concentration (LIC) and hepatic proton density fat fraction (PDFF) were analyzed prospectively in 68 dialysis patients by magnetic resonance imaging (MRI). Follow up of LIC and PDFF was performed in 17 dialysis patients during iron therapy. Findings PDFF differed significantly among dialysis patients classified according to LIC: patients with moderate or severe iron overload had increased fat fraction (PDFF: 7.9% (0.5–14.8%)) when compared to those with normal LIC (PDFF: 5% (0.27–11%)) or mild iron overload (PDFF: 5% (0.30–11.6%); P = 0.0049). PDFF correlated with LIC, and ferritin and body mass index. In seven patients monitored during IV iron therapy, LIC and PDFF increased concomitantly (PDFF: initial 2.5%, final 8%, P = 0.0156; LIC: initial 20 μmol/g, final 160 μmol/g: P = 0.0156), whereas in ten patients with iron overload, PDFF decreased after IV iron withdrawal or major dose reduction (initial: 8%, final: 4%; P = 0.0098) in parallel with LIC (initial: 195 μmol/g, final: 45 μmol/g; P = 0.002). Interpretation Liver iron load influences hepatic fat fraction in dialysis patients. Iron overload induced by iron therapy may aggravate or trigger NAFLD in dialysis patients. Trial registration number (ISRCTN) 80100088.
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Affiliation(s)
- Guy Rostoker
- Division of Nephrology and Dialysis, Ramsay Générale de Santé, Hôpital Privé Claude Galien, Quincy-Sous-Sénart, France.
| | - Christelle Loridon
- Division of Nephrology and Dialysis, Ramsay Générale de Santé, Hôpital Privé Claude Galien, Quincy-Sous-Sénart, France
| | - Mireille Griuncelli
- Division of Nephrology and Dialysis, Ramsay Générale de Santé, Hôpital Privé Claude Galien, Quincy-Sous-Sénart, France
| | - Clémentine Rabaté
- Division of Nephrology and Dialysis, Ramsay Générale de Santé, Hôpital Privé Claude Galien, Quincy-Sous-Sénart, France
| | - Fanny Lepeytre
- Division of Nephrology and Dialysis, Ramsay Générale de Santé, Hôpital Privé Claude Galien, Quincy-Sous-Sénart, France
| | - Pablo Ureña-Torres
- Division of Dialysis, Ramsay Générale de Santé, Clinique du Landy, Saint-Ouen, France
| | - Belkacem Issad
- Division of Nephrology and Dialysis, Assistance Publique Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Nasredine Ghali
- Division of Nephrology and Dialysis, Centre Hospitalier Marc Jacquet, Melun, France
| | - Yves Cohen
- Division of Radiology, Ramsay Générale de Santé, Hôpital Privé Claude Galien, Quincy-Sous-Sénart, France
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Ueda N, Takasawa K. Impact of Inflammation on Ferritin, Hepcidin and the Management of Iron Deficiency Anemia in Chronic Kidney Disease. Nutrients 2018; 10:nu10091173. [PMID: 30150549 PMCID: PMC6163440 DOI: 10.3390/nu10091173] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 08/08/2018] [Accepted: 08/17/2018] [Indexed: 12/16/2022] Open
Abstract
Iron deficiency anemia (IDA) is a major problem in chronic kidney disease (CKD), causing increased mortality. Ferritin stores iron, representing iron status. Hepcidin binds to ferroportin, thereby inhibiting iron absorption/efflux. Inflammation in CKD increases ferritin and hepcidin independent of iron status, which reduce iron availability. While intravenous iron therapy (IIT) is superior to oral iron therapy (OIT) in CKD patients with inflammation, OIT is as effective as IIT in those without. Inflammation reduces predictive values of ferritin and hepcidin for iron status and responsiveness to iron therapy. Upper limit of ferritin to predict iron overload is higher in CKD patients with inflammation than in those without. However, magnetic resonance imaging studies show lower cutoff levels of serum ferritin to predict iron overload in dialysis patients with apparent inflammation than upper limit of ferritin proposed by international guidelines. Compared to CKD patients with inflammation, optimal ferritin levels for IDA are lower in those without, requiring reduced iron dose and leading to decreased mortality. The management of IDA should differ between CKD patients with and without inflammation and include minimization of inflammation. Further studies are needed to determine the impact of inflammation on ferritin, hepcidin and therapeutic strategy for IDA in CKD.
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Affiliation(s)
- Norishi Ueda
- Department of Pediatrics, Public Central Hospital of Matto Ishikawa, 3-8 Kuramitsu, Hakusan, Ishikawa 924-8588, Japan.
| | - Kazuya Takasawa
- Department of Internal Medicine, Public Central Hospital of Matto Ishikawa, 3-8 Kuramitsu, Hakusan, Ishikawa 924-8588, Japan.
- Department of Internal Medicine, Public Tsurugi Hospital, Ishikawa 920-2134, Japan.
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Rostoker G. When should iron supplementation in dialysis patients be avoided, minimized or withdrawn? Semin Dial 2018; 32:22-29. [PMID: 29956370 PMCID: PMC7379289 DOI: 10.1111/sdi.12732] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Parenteral iron is used to restore the body's iron pool before and during erythropoiesis‐stimulating agent (ESA) therapy; together these agents form the backbone of anemia management in end‐stage renal disease (ESRD) patients undergoing hemodialysis. ESRD patients receiving chronic intravenous iron products, which exceed their blood loss are exposed to an increased risk of positive iron balance. Measurement of the liver iron concentration (LIC) reflects total body iron stores in patients with secondary hemosiderosis and genetic hemochromatosis. Recent studies of LIC in hemodialysis patients, measured by quantitative MRI and magnetic susceptometry, have demonstrated a high risk of iron overload in dialysis patients treated with IV iron products at doses advocated by current anemia management guidelines for dialysis patients. Liver iron overload causes increased production of hepcidin and elevated plasma levels, which can activate macrophages of atherosclerotic plaques. This mechanism may explain the results of 3 long‐term epidemiological studies which showed the association of excessive IV iron doses with increased risk of cardiovascular morbidity and mortality among hemodialysis patients. A more physiological approach of iron therapy in ESRD is needed. Peritoneal dialysis patients, hemodialysis patients infected with hepatitis C virus, and hemodialysis patients with ferritin above 1000 μg/L without a concomitant inflammatory state, all require specific and cautious iron management. Two recent studies have shown that most hemodialysis patients will benefit from lower maintenance IV iron dosages; their results are applicable to American hemodialysis patients. Novel pharmacometric and economic approaches to iron therapy and anemia management are emerging which are designed to lessen the potential side effects of excessive IV iron while maintaining hemoglobin stability without an increase in ESA dosing.
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Affiliation(s)
- Guy Rostoker
- Ramsay-Générale de Santé, Division of Nephrology and Dialysis, Hôpital Privé Claude Galien, Quincy sous Sénart, France
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Piotti G, Gandolfini I, Palmisano A, Maggiore U. Metabolic risk profile in kidney transplant candidates and recipients. Nephrol Dial Transplant 2018; 34:388-400. [DOI: 10.1093/ndt/gfy151] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 05/01/2018] [Indexed: 12/30/2022] Open
Affiliation(s)
- Giovanni Piotti
- Department of Nephrology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Ilaria Gandolfini
- Department of Nephrology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Alessandra Palmisano
- Department of Nephrology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Umberto Maggiore
- Department of Nephrology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
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24
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Vela D. Balance of cardiac and systemic hepcidin and its role in heart physiology and pathology. J Transl Med 2018; 98:315-326. [PMID: 29058707 DOI: 10.1038/labinvest.2017.111] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 08/23/2017] [Accepted: 08/24/2017] [Indexed: 02/07/2023] Open
Abstract
Hepcidin is the main regulator of iron metabolism in tissues. Its serum levels are mostly correlated with the levels of hepcidin expression from the liver, but local hepcidin can be important for the physiology of other organs as well. There is an increasing evidence that this is the case with cardiac hepcidin. This has been confirmed by studies with models of ischemic heart disease and other heart pathologies. In this review the discussion dissects the role of cardiac hepcidin in cellular homeostasis. This review is complemented with examination of the role of systemic hepcidin in heart disease and its use as a biochemical marker. The relationship between systemic vs local hepcidin in the heart is important because it can help us understand how the fine balance between the actions of two hepcidins affects heart function. Manipulating the axis systemic/cardiac hepcidin could serve as a new therapeutic strategy in heart diseases.
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Affiliation(s)
- Driton Vela
- Department of Physiology, Faculty of Medicine, University of Prishtina, Prishtina, Kosova
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25
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Relation between high serum hepcidin-25 level and subclinical atherosclerosis and cardiovascular mortality in hemodialysis patients. Anatol J Cardiol 2018; 19:117-122. [PMID: 29339674 PMCID: PMC5864805 DOI: 10.14744/anatoljcardiol.2017.8019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE In hemodialysis (HD) patients, cardiovascular disease (CVD) is the major cause of mortality and morbidity. In atherosclerotic diseases, iron gets accumulated in the arterial wall. Hepcidin is an important hormone in iron metabolism. Furthermore, hepcidin is associated with atherosclerotic disease. Therefore, this study aims to investigate the relation of serum hepcidin-25 (SH-25) and sub-clinic atherosclerosis measured by carotid intima-media thickness (CIMT) and mortality in HD patients. METHODS We enrolled 82 HD patients in a cross-control study. We measured SH-25 using ELISA kit and CIMT using high-resolution real-time ultrasonography. After 4 years of first assessment, we investigated the relation between all-cause and cardiovascular mortality and SH-25 and CIMT. RESULTS Two patients were excluded because of renal transplantation. The survivors were younger (53.7±15.1 vs. 65.2±15.5; p<0.05) and CIMT was lower (0.83±0.2 vs. 0.95±0.2; p<0.05); however, there was no significant difference in SH-25 levels between the groups (29.1±13 vs. 32.4±22.4; p=0.767). The patients who died of CVD were significantly older (63.7±16.1 vs. 53.7±15.1; p<0.05) and had significantly higher CIMT (0.94±0.2 vs. 83±0.2; p<0.05). The SH-25 levels were statistically significantly higher in patients who died of CVD (40.3±25 vs. 29.1±13; p<0.05). Linear regression analysis showed a positive correlation between CIMT and SH-25 in the study population and in those who died from CVD (r=0.41; p<0.05 and r=0.606; p<0.05, respectively). CONCLUSION This study suggests that hepcidin is effective in cardiovascular mortality and pathophysiology of subclinical atherosclerosis in HD patients.
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Fernández-Ruiz M, Parra P, Ruiz-Merlo T, López-Medrano F, San Juan R, Polanco N, González E, Andrés A, Aguado JM. Association between baseline serum hepcidin levels and infection in kidney transplant recipients: Potential role for iron overload. Transpl Infect Dis 2018; 20. [PMID: 29120522 DOI: 10.1111/tid.12807] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 05/23/2017] [Accepted: 07/13/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND The liver-synthesized peptide hepcidin is a key regulator of iron metabolism and correlates with total iron stores. We analyzed the association between pre-transplant hepcidin-25 levels and infection after kidney transplantation (KT). METHODS Serum hepcidin-25 levels were measured at baseline by high-sensitivity ELISA in 91 patients undergoing KT at our institution between December 2011 and March 2013. The impact of this biomarker on the incidence of post-transplant infection (excluding lower urinary tract infection) during the first year was assessed by Cox regression. RESULTS Mean hepcidin-25 level was 82.3 ± 67.4 ng/mL and strongly correlated with serum ferritin (Spearman's rho = 0.703; P < .001). There were no significant differences in hepcidin-25 levels between patients with or without overall infection (96.4 ± 67.5 vs 72.6 ± 66.7 ng/mL; P = .101). Such difference was evident for opportunistic (128.9 ± 75.0 vs 73.0 ± 62.3 ng/mL; P = .003) and, to a lesser extent, surgical-site infection (107.5 ± 73.3 vs 76.5 ± 65.2 ng/mL; P = .087). Patients with hepcidin-25 levels ≥72.5 ng/mL had higher 12-month cumulative incidence of overall infection (51.2% vs 29.2%; P = .032). After multivariate adjustment, hepcidin-25 ≥72.5 ng/mL acted as an independent risk factor for overall (adjusted hazard ratio [aHR] 3.86; 95% confidence interval [CI] 1.49-9.96; P = .005) and opportunistic infection (aHR 4.32; 95% CI 1.18-15.75; P = .027). CONCLUSION Elevated baseline serum hepcidin-25 levels were associated with increased risk of infection after KT, suggesting a role for iron overload in the individual susceptibility to post-transplant infection.
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Affiliation(s)
- Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - Patricia Parra
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - Tamara Ruiz-Merlo
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - Francisco López-Medrano
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - Rafael San Juan
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - Natalia Polanco
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - Esther González
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - Amado Andrés
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
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Associations of plasma hepcidin with mortality risk in patients with coronary artery disease. Oncotarget 2017; 8:109497-109508. [PMID: 29312624 PMCID: PMC5752537 DOI: 10.18632/oncotarget.22722] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 07/06/2017] [Indexed: 12/18/2022] Open
Abstract
Background Increased blood hepcidin may be associated with the presence and promotion of atherosclerosis, the association of hepcidin with mortality among coronary artery disease (CAD) patients remains unknown. We sought to assess the relationship of hepcidin and all-cause and cardiovascular disease (CVD) mortality among CAD patients with and without acute coronary syndrome (ACS). Methods and Results This study included 759 patients with ACS and 526 patients with stable CAD. After an average follow-up of 4.1 years, 154 deaths were recorded, 114 were due to CVD. After adjusting for CVD risk factors and inflammatory markers, the plasma hepcidin was positively associated with all-cause and CVD mortality in the ACS patients, the multivariable-adjusted hazard ratios (HRs) across tertiles of hepcidin were 1.00, 2.18 (95% CI 1.23-3.94), and 2.82 (95% CI 1.59-5.12) for all-cause mortality (Ptrend=0.006), and 1.00, 2.20 (95% CI 1.12-4.05), and 2.64 (95% CI 1.41-5.65) for CVD mortality (Ptrend=0.01). The C-index and net reclassification improvement when including hepcidin in traditional CVD models were 1.6% and 21.5% for all-cause mortality, 1.4% and 23.5% for CVD mortality, respectively, (P<0.001). Conclusions Plasma hepcidin was positively associated with mortality in ACS patients. Hepcidin may be a potential biomarker for risk prediction in ACS patients.
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28
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Rostoker G. The changing landscape of iron overload disorders at the beginning of the 21st century. Presse Med 2017; 46:e269-e271. [PMID: 29169711 DOI: 10.1016/j.lpm.2017.10.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 10/04/2017] [Indexed: 12/29/2022] Open
Affiliation(s)
- Guy Rostoker
- Hôpital privé Claude-Galien, Ramsay-Générale de Santé, Division of Nephrology and Dialysis, Quincy-sous-Sénart, France.
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29
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Iatrogenic iron overload and its potential consequences in patients on hemodialysis. Presse Med 2017; 46:e312-e328. [PMID: 29153377 DOI: 10.1016/j.lpm.2017.10.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 10/03/2017] [Accepted: 10/10/2017] [Indexed: 12/13/2022] Open
Abstract
Iron overload was considered rare in hemodialysis patients until recently, but its clinical frequency is now increasingly recognized. The liver is the main site of iron storage and the liver iron concentration (LIC) is closely correlated with total iron stores in patients with secondary hemosiderosis and genetic hemochromatosis. Magnetic resonance imaging (MRI) is now the gold standard method for estimating and monitoring LIC. Studies of LIC in hemodialysis patients by magnetic susceptometry thirteen years ago and recently by quantitative MRI have demonstrated a relation between the risk of iron overload and the use of intravenous (IV) iron products prescribed at doses determined by the iron biomarker cutoffs contained in current anemia management guidelines. These findings have challenged the validity of both iron biomarker cutoffs and current clinical guidelines, especially with respect to recommended IV iron doses. Moreover, three recent long-term observational studies suggested that excessive IV iron doses might be associated with an increased risk of cardiovascular events and death in hemodialysis patients. It has been hypothesized that iatrogenic iron overload in the era of erythropoiesis-stimulating agents might silently increase complications in dialysis patients without creating obvious, clinical signs and symptoms. High hepcidin-25 levels were recently linked to fatal and nonfatal cardiovascular events in dialysis patients. It has been postulated that the main pathophysiological pathway leading to these events might involve the pleiotropic master hormone hepcidin, which regulates iron metabolism, leading to activation of macrophages in atherosclerotic plaques and then to clinical cardiovascular events. Thus, the potential iron overload toxicity linked to chronic administration of IV iron therapy is now becoming one of the most controversial topics in the management of anemia in hemodialysis patients.
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30
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Li X, Kshirsagar AV, Brookhart MA. Safety of intravenous iron in hemodialysis patients. Hemodial Int 2017; 21 Suppl 1:S93-S103. [PMID: 28370957 DOI: 10.1111/hdi.12558] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Among end-stage renal disease patients maintained by hemodialysis, anemia has been managed primarily through erythropoiesis-stimulating agents (ESAs) and intravenous (IV) iron. Following concerns about the cardiovascular (CV) safety of ESAs and changes in the reimbursement policies in Medicare's ESRD program, the use of IV iron has increased. IV iron supplementation promotes hemoglobin production and reduces ESA requirements, yet there exists relatively little evidence on the long-term safety of iron supplementation in hemodialysis patients. Labile iron can induce oxidative stress and is also essential in bacterial growth, leading to concerns about IV iron use and risk of CV events and infections in hemodialysis patients. Existing randomized controlled trials provide little evidence about safety due to insufficient power and short follow-up; recent observational studies have been inconsistent, but some have associated iron exposure with increased risk of infections and CV events. Given the widespread use and potential safety concerns related to IV iron, well-designed large prospective studies are needed to assess to identify optimal strategies for iron administration that maximize its benefits while avoiding potential risks.
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Affiliation(s)
- Xiaojuan Li
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Abhijit V Kshirsagar
- UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - M Alan Brookhart
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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31
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Petrulienė K, Žiginskienė E, Kuzminskis V, Nedzelskienė I, Bumblytė IA. Hepcidin serum levels and resistance to recombinant human erythropoietin therapy in hemodialysis patients. MEDICINA-LITHUANIA 2017; 53:90-100. [PMID: 28416170 DOI: 10.1016/j.medici.2017.03.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 11/25/2016] [Accepted: 03/20/2017] [Indexed: 02/09/2023]
Abstract
OBJECTIVE The aim of this study was to analyze the factors that are associated with the response to erythropoiesis-stimulating agents (ESAs) and its association with hospitalization and mortality rates; to evaluate the serum hepcidin level and its associations with iron profile, inflammatory markers, ESA responsiveness, and mortality; and to determine independent factors affecting ERI and hepcidin. MATERIALS AND METHODS To evaluate a dose-response effect of ESAs we used the erythropoietin resistance index (ERI). Patients were stratified in two groups: nonresponders and responders (ERI>15, n=20, and ERI ≤15U/kg/week/g per 100mL, n=153, respectively). Hematological data, hepcidin levels, iron parameters, inflammatory markers, hospitalization and mortality rates were compared between the groups. Multiple regression analysis was used to determine independent factors affecting ERI and hepcidin. RESULTS C-reactive protein (CRP) (β=0.078, P=0.007), albumin (β=-0.436, P=0.004), body mass index (β=-0.374, P<0.001), and hospitalization rate per year (β=3.017, P<0.001) were found to be significant determinants of ERI in maintenance hemodialysis (MHD) patients. Inadequate dialysis was associated with higher ERI. Patients with concomitant oncological diseases had higher ERI (31.2±12.4 vs 9.7±8.1U/kg/week/g per 100mL, P=0.002). The hepcidin level was 158.51±162.57 and 120.65±67.28ng/mL in nonresponders and responders, respectively (P=0.33). Hepcidin correlated directly with ERI, dose of ESAs, ferritin and inversely with Hb, transferrin saturation, and albumin. ERI (β=4.869, P=0.002) and ferritin (β=0.242, P=0.003) were found to be significant determinants of hepcidin in MHD patients. The hospitalization rate per year was 2.35±1.8 and 1.04±1.04 in nonresponders and responders, respectively (P=0.011). The mean length of one hospitalization was 25.12±21.26 and 10.82±17.25 days, respectively (P=0.012). Death occurred in 30% of the patients from the responders' group and in 50% from the nonresponders' group (P=0.289). The mean hepcidin concentration of patients who died was 141.9±129.62ng/mL and who survived, 132.98±109.27ng/mL (P=0.797). CONCLUSIONS CRP, albumin, BMI, and hospitalization rate per year were found to be significant determinants of ERI in MHD patients. Inadequate dialysis was associated with higher epoetin requirements. There were no difference in patient mortality by ERI, but a significant difference in hospitalization rates and mean length of one hospitalization was revealed. A significant positive relation between hepcidin and ERI was revealed. ERI and ferritin were found to be significant determinants of hepcidin in MHD patients. Hepcidin was not related to mortality.
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Affiliation(s)
- Kristina Petrulienė
- Department of Nephrology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania.
| | - Edita Žiginskienė
- Department of Nephrology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Vytautas Kuzminskis
- Department of Nephrology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Irena Nedzelskienė
- Department of Odontology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Inga Arūnė Bumblytė
- Department of Nephrology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
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Tessitore N, Poli A, Bedogna V, Corazza L, Campostrini N, Atti M, Sereni L, Castagna A, Girelli D, Pessolano G, Lupo A. A single dialysis session of hemodiafiltration with sorbent-regenerated endogenous ultrafiltrate reinfusion (HFR) removes hepcidin more efficiently than bicarbonate hemodialysis: a new approach to containing hepcidin burden in dialysis patients? J Nephrol 2017; 31:297-306. [PMID: 28353202 DOI: 10.1007/s40620-017-0383-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 02/22/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Most hemodialysis patients have high Hepcidin-25 levels, which may be involved in the pathogenesis of several uremic complications related to an altered iron biology. The hemodialysis procedure itself can influence Hepcidin-25 levels by removing Hepcidin-25 and maybe stimulating its production due to a pro-inflammatory effect. METHODS To assess the relationship between dialysis-related inflammation and intradialysis changes in Hepcidin-25, we performed a crossover trial in 28 hemodialysis patients to compare the effects on serum levels of Hepcidin-25 and inflammatory markers activated during dialysis [Tumor Necrosis Factor-α (TNF-α), Interleukin-6, C-reactive protein (CRP), Pentraxin-3] of a single dialysis session using a technique capable of reducing inflammation, HFR (Hemo Filtrate Reinfusion: a hemodiafiltration system combining convection, diffusion and adsorption) or bicarbonate-dialysis using either the same low-flux membrane as in the diffusion stage of HFR (LFBD) or a high-flux membrane (HFBD). RESULTS HFR achieved a greater reduction in Hepcidin-25 levels than both LFBD [-72% (95% CI: -11 to -133), p = 0.022] and HFBD [-137% (95% CI: -2 to -272), p = 0.047], conceivably due to both a greater removal (because of its convective/adsorptive component) and a lower inflammation-related Hepcidin-25 production. HFR also led to a greater decrease in TNF-α than LFBD [-277% (95% CI: -59 to -494), p = 0.014], while the two methods induced similar changes in Interleukin-6, CRP and Pentraxin-3 levels. CONCLUSIONS Our findings suggest that a single bicarbonate-dialysis session can upregulate Hepcidin-25 synthesis and that HFR can fully overcome this effect, enabling a greater Hepcidin-25 removal during dialysis. Adequately-designed studies are needed, however, to establish whether the beneficial effect of HFR emerging from our study could reduce Hepcidin-25 (and TNF-α) burden and improve clinically-relevant outcomes. TRIAL REGISTRATION ISRCTN15957905.
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Affiliation(s)
- Nicola Tessitore
- Emodialisi Borgo Roma, Nephrology Section, Department of Medicine, University of Verona, Piazzale LA Scuro 10, 37134, Verona, Italy.
| | - Albino Poli
- Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Valeria Bedogna
- Emodialisi Borgo Roma, Nephrology Section, Department of Medicine, University of Verona, Piazzale LA Scuro 10, 37134, Verona, Italy
| | | | - Natascia Campostrini
- Internal Medicine Section, Department of Medicine, University of Verona, Verona, Italy
| | | | | | - Annalisa Castagna
- Internal Medicine Section, Department of Medicine, University of Verona, Verona, Italy
| | - Domenico Girelli
- Internal Medicine Section, Department of Medicine, University of Verona, Verona, Italy
| | - Giuseppina Pessolano
- Emodialisi Borgo Roma, Nephrology Section, Department of Medicine, University of Verona, Piazzale LA Scuro 10, 37134, Verona, Italy
| | - Antonio Lupo
- Emodialisi Borgo Roma, Nephrology Section, Department of Medicine, University of Verona, Piazzale LA Scuro 10, 37134, Verona, Italy
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33
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Rostoker G, Vaziri ND. Impact of iatrogenic iron overload on the course of hepatitis C in the dialysis population: A plea for caution. Hemodial Int 2017; 21 Suppl 1:S68-S77. [PMID: 28332306 DOI: 10.1111/hdi.12557] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
About 2.5% of the world population, corresponding to about 177 million individuals, are infected by hepatitis C virus (HCV), a small, single-stranded RNA virus. The prevalence of HCV infection among dialysis patients in Japan, Europe, and North America during the 2012 to 2015 period was found to be 8.7% in the DOPPS study. Nosocomial HCV spread in hemodialysis facilities still occurs. Increased hepatic tissue iron has been shown to play a deleterious role in the course of hepatitis C, favor development of fibrosis and cirrhosis and possibly increase the risk of liver cancer in the general population. Regular loss of blood in the hemodialysis circuit, in routine blood sampling for laboratory tests (for uremia monitoring), and in gut due to uremic enteropathy, invariably results in iron deficiency for which patients are commonly treated with intravenous (IV) iron preparations. Data on the effects of IV iron in hemodialysis patients with hepatitis C are limited (2 studies) and strongly suggest that parenteral iron may contribute to hepatocellular injury. Iatrogenic iron overload is extremely prevalent among hemodialysis population worldwide. Iron overload and toxicity has emerged as one of the most controversial topic in the management of anemia in dialysis patients. Given the known impact of iron in promoting growth and virulence of HCV and the associated liver disease, it is necessary to use iron therapy cautiously and closely monitor plasma markers of iron metabolism and liver iron stores non-invasively by means of MRI to avoid iron overload in this vulnerable population.
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Affiliation(s)
- Guy Rostoker
- Division of Nephrology and Dialysis, Hôpital Privé Claude Galien, Ramsay-Générale de Santé, Quincy sous Sénart, France
| | - Nosratola D Vaziri
- Division of Nephrology and Hypertension, University of California, Irvine, California, USA
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34
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Rostoker G, Vaziri ND, Fishbane S. Iatrogenic Iron Overload in Dialysis Patients at the Beginning of the 21st Century. Drugs 2017; 76:741-57. [PMID: 27091216 PMCID: PMC4848337 DOI: 10.1007/s40265-016-0569-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Iron overload used to be considered rare in hemodialysis patients but its clinical frequency is now increasingly realized. The liver is the main site of iron storage and the liver iron concentration (LIC) is closely correlated with total iron stores in patients with secondary hemosideroses and genetic hemochromatosis. Magnetic resonance imaging is now the gold standard method for LIC estimation and monitoring in non-renal patients. Studies of LIC in hemodialysis patients by quantitative magnetic resonance imaging and magnetic susceptometry have demonstrated a strong relation between the risk of iron overload and the use of intravenous (IV) iron products prescribed at doses determined by the iron biomarker cutoffs contained in current anemia management guidelines. These findings have challenged the validity of both iron biomarker cutoffs and current clinical guidelines, especially with respect to recommended IV iron doses. Three long-term observational studies have recently suggested that excessive IV iron doses may be associated with an increased risk of cardiovascular events and death in hemodialysis patients. We postulate that iatrogenic iron overload in the era of erythropoiesis-stimulating agents may silently increase complications in dialysis patients without creating frank clinical signs and symptoms. High hepcidin-25 levels were recently linked to fatal and nonfatal cardiovascular events in dialysis patients. It is therefore tempting to postulate that the main pathophysiological pathway leading to these events may involve the pleiotropic master hormone hepcidin (synergized by fibroblast growth factor 23), which regulates iron metabolism. Oxidative stress as a result of IV iron infusions and iron overload, by releasing labile non-transferrin-bound iron, might represent a ‘second hit’ on the vascular bed. Finally, iron deposition in the myocardium of patients with severe iron overload might also play a role in the pathogenesis of sudden death in some patients.
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Affiliation(s)
- Guy Rostoker
- Division of Nephrology and Dialysis, Hôpital Privé Claude Galien, Ramsay-Générale de Santé, Quincy sous Sénart, France. .,Service de Néphrologie et de Dialyse, HP Claude Galien, 20 route de Boussy, Quincy sous Sénart, 91480, France.
| | - Nosratola D Vaziri
- Division of Nephrology and Hypertension, University of California, Irvine, CA, USA
| | - Steven Fishbane
- Division of Nephrology, Hofstra North-Shore-LIJ School of Medicine, Great Neck, New York, NY, USA
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Sakamoto S, Kawabata H, Kanda J, Uchiyama T, Mizumoto C, Kitano T, Kondo T, Hishizawa M, Tomosugi N, Takaori-Kondo A. High pretransplant hepcidin levels are associated with poor overall survival and delayed platelet engraftment after allogeneic hematopoietic stem cell transplantation. Cancer Med 2016; 6:120-128. [PMID: 27905193 PMCID: PMC5269567 DOI: 10.1002/cam4.974] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 10/11/2016] [Accepted: 10/31/2016] [Indexed: 12/13/2022] Open
Abstract
Iron overload is considered a risk factor for mortality in patients with hematopoietic malignancies. Hepcidin is a key regulator of systemic iron balance. We previously reported dynamic changes of serum hepcidin‐25 levels in patients with hematologic malignancies after allogeneic hematopoietic stem cell transplantation (allo‐HSCT). In this study, we retrospectively analyzed the association of pretransplant hepcidin‐25 levels with overall survival (OS), engraftment, and other clinical outcomes of allo‐HSCT in patients with hematologic malignancies. A total of 166 patients were divided into two groups depending on their pretransplant serum hepcidin‐25 levels; their median age was 49.5 years, and the median follow‐up time was 46.8 months. At 3 years, the patients in the high‐hepcidin group had a significantly lower OS than those in the low‐hepcidin group (49.2 vs. 69.0%, respectively; P = 0.006). Multivariate analysis revealed that pretransplant serum hepcidin‐25 level, sex, and disease status were independently associated with OS. The incidence of platelet engraftment was significantly lower in the high‐hepcidin group than in the low‐hepcidin group, whereas no significant differences were observed in neutrophil and reticulocyte engraftments between these groups. Hence, pretransplant serum hepcidin levels can be a marker for predicting delayed platelet recovery after allo‐HSCT.
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Affiliation(s)
- Soichiro Sakamoto
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroshi Kawabata
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Department of Hematology and Immunology, Kanazawa Medical University, Uchinada-machi, Japan
| | - Junya Kanda
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tatsuki Uchiyama
- Department of Hematology and Immunology, Japanese Red Cross Otsu Hospital, Otsu, Japan
| | - Chisaki Mizumoto
- Department of Hematology and Immunology, Japanese Red Cross Otsu Hospital, Otsu, Japan
| | - Toshiyuki Kitano
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tadakazu Kondo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masakatsu Hishizawa
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Naohisa Tomosugi
- Division of Advanced Medicine, Medical Research Institute, Kanazawa Medical University, Uchinada-machi, Japan
| | - Akifumi Takaori-Kondo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Sawa J, Inaba M, Noguchi K, Nakagawa C, Kuwamura M, Kuwamura Y, Wada N, Kitatani K, Kawaguchi Y, Kumeda Y. Effects of darbepoetin alfa and epoetin beta pegol on iron kinetics in hemodialysis patients. RENAL REPLACEMENT THERAPY 2016. [DOI: 10.1186/s41100-016-0037-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Eisenga MF, Dullaart RPF, Berger SP, Sloan JH, de Vries APJ, Bakker SJL, Gaillard CAJM. Association of hepcidin-25 with survival after kidney transplantation. Eur J Clin Invest 2016; 46:994-1001. [PMID: 27696386 PMCID: PMC5132077 DOI: 10.1111/eci.12682] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 09/29/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hepcidin is considered the master regulator of iron homoeostasis. Novel hepcidin antagonists have recently been introduced as potential treatment for iron-restricted anaemia. Meanwhile, serum hepcidin has been shown to be positively associated with cardiovascular disease and inversely with acute kidney injury. These properties may lead to contrasting effects, especially in renal transplant recipients (RTR), which are prone to cardiovascular diseases and graft failure. To date, the role of serum hepcidin in RTR is unknown. We, therefore, prospectively determined the association of serum hepcidin with risk of graft failure, cardiovascular mortality and all-cause mortality in RTR. MATERIALS AND METHODS Serum hepcidin was assessed in an extensively phenotyped RTR cohort by dual-monoclonal sandwich ELISA specific immunoassay. Statistical analyses were performed using univariate linear regression followed by stepwise backward linear regression. Cox proportional hazard regression models were performed to determine prospective associations. RESULTS We included 561 RTR (age 51 ± 12 years). Mean haemoglobin (Hb) was 8·6 ± 1·0 mM. Median [IQR] serum hepcidin was 7·2 [3·2-13·4] ng/mL. Mean estimated glomerular filtration rate was 47 ± 16 mL/min/1·73 m2 . In univariate Cox regression analyses, serum hepcidin was not associated with risk of graft failure, cardiovascular mortality or all-cause mortality. Notably, after adjustment for high sensitivity C-reactive protein and ferritin, serum hepcidin became negatively associated with all-cause mortality (hazard ratio 0·89; 95% confidence interval 0·80-0·99, P = 0·03). CONCLUSIONS In this study, we did not find an association between serum hepcidin and outcomes, that is graft failure, cardiovascular mortality or all-cause mortality. Based on our results, it is questionable whether serum hepcidin may be used to predict a beneficial effect of hepcidin antagonists.
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Affiliation(s)
- Michele F Eisenga
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, Groningen, the Netherlands
| | - Robin P F Dullaart
- Division of Endocrinology, Department of Internal Medicine, University Medical Center Groningen, Groningen, the Netherlands
| | - Stefan P Berger
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, Groningen, the Netherlands
| | - John H Sloan
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Aiko P J de Vries
- Division of Nephrology, Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Stephan J L Bakker
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, Groningen, the Netherlands
| | - Carlo A J M Gaillard
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, Groningen, the Netherlands
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Klip IJT, Voors AA, Swinkels DW, Bakker SJL, Kootstra-Ros JE, Lam CS, van der Harst P, van Veldhuisen DJ, van der Meer P. Serum ferritin and risk for new-onset heart failure and cardiovascular events in the community. Eur J Heart Fail 2016; 19:348-356. [PMID: 27758018 DOI: 10.1002/ejhf.622] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 06/30/2016] [Accepted: 07/04/2016] [Indexed: 12/20/2022] Open
Abstract
AIMS Heart failure (HF) is a common manifestation of patients with primary and secondary causes of iron overload, whereas in patients with established HF iron deficiency impairs outcome. Whether iron stores, either depleted or in overload, amplify the risk for new-onset HF among healthy individuals is unknown. The present study aimed to assess whether markers of iron status or the iron-regulatory hormone hepcidin are associated with new-onset HF or cardiovascular (CV) events in the general population. METHODS AND RESULTS In 6386 subjects from the Prevention of REnal and Vascular ENd-stage Disease (PREVEND) trial, a prospective, community-based, cohort study, markers of iron status and the iron-regulatory hormone hepcidin were measured. Mean age was 53.1 ± 12.0 years, and 50.7% of the cohort was female. During a median follow-up of 8.3 (interquartile range 7.8-8.9) years, 199 subjects (3.1%) were newly diagnosed with HF, 456 (7.1%) experienced a CV event, and 356 (5.6%) died from all causes. A higher annual HF incidence per ferritin quartile was observed in women (P < 0.001), but not in men (P for interaction 0.032). Multivariable analyses demonstrated ferritin levels to remain independently predictive for new-onset HF in women only (P = 0.024). This association persisted within strata defined by markers of the metabolic syndrome, markers of inflammation, or other markers of iron homeostasis, including hepcidin. No association between ferritin or hepcidin and incident CV events or all-cause mortality was observed in either sex. CONCLUSIONS Increased serum ferritin levels independently amplify the risk for new-onset HF in women in the community.
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Affiliation(s)
- IJsbrand T Klip
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Adriaan A Voors
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Dorine W Swinkels
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Stephan J L Bakker
- Department of Nephrology, University Medical Center Groningen, Groningen, The Netherlands
| | - Jenny E Kootstra-Ros
- Department of Laboratory Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Carolyn S Lam
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Pim van der Harst
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
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Deira J, González-Sanchidrián S, Polanco S, Cebrián C, Jiménez M, Marín J, Gómez-Martino JR, Fernández-Pereira L, Tabernero J. Very low doses of direct intravenous iron in each session as maintenance therapy in hemodialysis patients. Ren Fail 2016; 38:1076-81. [DOI: 10.1080/0886022x.2016.1184937] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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40
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Honda H, Kobayashi Y, Onuma S, Shibagaki K, Yuza T, Hirao K, Yamamoto T, Tomosugi N, Shibata T. Associations among Erythroferrone and Biomarkers of Erythropoiesis and Iron Metabolism, and Treatment with Long-Term Erythropoiesis-Stimulating Agents in Patients on Hemodialysis. PLoS One 2016; 11:e0151601. [PMID: 26978524 PMCID: PMC4792384 DOI: 10.1371/journal.pone.0151601] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 03/01/2016] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND We aimed to identify associations between erythroferrone (ERFE), a regulator of hepcidin 25, and biomarkers of erythropoiesis and iron metabolism. We also aimed to determine the effects of erythropoiesis-stimulating agents (ESA), continuous erythropoietin receptor activator (CERA) and darbepoetin-α (DA) on ERFE production in patients on hemodialysis (HD). METHODS Blood samples were obtained from 59 patients before HD sessions on day 0 (baseline). Twenty patients who were injected with either CERA (N = 10) or DA (N = 10) at the end of the dialysis week (day 0), who had ferritin ≥ 100 ng/mL and/or transferrin saturation ≥ 20%, and hemoglobin > 9 g/dL were selected from among the 59 patients. Blood was sampled serially before HD sessions on days 3, 5, 7 from patients on DA and on the same days plus day 14 from those on CERA. RESULTS Levels of ERFE correlated inversely with those of hepcidin 25 and ferritin, and positively with those of soluble transferrin receptor. The hepcidin 25: ERFE ratio and hepcidin 25 levels positively correlated with ferritin levels. Levels of ERFE significantly increased from day 3 of treatment with DA and CERA and decreased by days 7 and 14, respectively. Erythropoiesis-stimulating agents concomitantly decreased levels of hepcidin 25 as those of ERFE increased. CONCLUSION We identified a novel association between ESA and ERFE in patients on HD. Both DA and CERA increased levels of ERFE that regulated hepcidin 25 and led to iron mobilization from body stores during erythropoiesis.
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Affiliation(s)
- Hirokazu Honda
- Division of Nephrology, Department of Medicine, Showa University Koto Toyusu Hospital, Tokyo, Japan
- * E-mail:
| | - Yasuna Kobayashi
- Division of Clinical Pharmacy, Department of Pharmacotherapeutics, Showa University, School of Pharmacy, Tokyo, Japan
| | - Shoko Onuma
- Division of Nephrology, Department of Medicine, Showa University, School of Medicine, Tokyo, Japan
| | | | | | | | - Toshinori Yamamoto
- Division of Clinical Pharmacy, Department of Pharmacotherapeutics, Showa University, School of Pharmacy, Tokyo, Japan
| | - Naohisa Tomosugi
- Aging Research Unit, Department of Advanced Medicine, Medical Research Institute, Kanazawa Medical University, Kanazawa, Japan
| | - Takanori Shibata
- Division of Nephrology, Department of Medicine, Showa University, School of Medicine, Tokyo, Japan
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Yousaf F, Spinowitz B. Hypoxia-Inducible Factor Stabilizers: a New Avenue for Reducing BP While Helping Hemoglobin? Curr Hypertens Rep 2016; 18:23. [DOI: 10.1007/s11906-016-0629-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Noguchi-Sasaki M, Sasaki Y, Matsuo-Tezuka Y, Yasuno H, Kurasawa M, Yorozu K, Shimonaka Y. Reduction of a marker of oxidative stress with enhancement of iron utilization by erythropoiesis activation following epoetin beta pegol administration in iron-loaded db/db mice. Int J Hematol 2016; 103:262-73. [PMID: 26739261 DOI: 10.1007/s12185-015-1929-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Revised: 12/09/2015] [Accepted: 12/11/2015] [Indexed: 01/01/2023]
Abstract
UNLABELLED Iron, an essential element for various biological processes, can induce oxidative stress. We hypothesized that iron utilization for erythropoiesis, stimulated by epoetin beta pegol (C.E.R.A.), a long-acting erythropoiesis-stimulating agent, contributes to the reduction of iron-induced oxidative stress. We first investigated the sensitivity of several biomarkers to detect oxidative stress in mice by altering the amount of total body iron; we then investigated whether C.E.R.A. ameliorated oxidative stress through enhanced iron utilization. We treated db/db mice with intravenous iron-dextran and evaluated several biomarkers of iron-induced oxidative stress. In mice loaded with 5 mg/head iron, hepatic iron content was elevated and the oxidative stress marker d-ROMs (serum derivatives of reactive oxygen metabolites) was increased, whereas urinary 8-hydroxy-2'-deoxyguanosine and serum malondialdehyde were not, indicating that d-ROMs is a sensitive marker of iron-induced oxidative stress. To investigate whether C.E.R.A. ameliorated oxidative stress, db/db mice were intravenously administered iron-dextran or dextran only, followed by C.E.R.A. Hemoglobin level increased, while hepatic iron content decreased after C.E.R.A. TREATMENT Serum d-ROMs decreased after C.E.R.A. treatment in the iron-dextran-treated group. Our results suggest that C.E.R.A. promotes iron utilization for erythropoiesis through mobilization of hepatic iron storage, leading to a decrease in serum oxidative stress markers in iron-loaded db/db mice.
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Affiliation(s)
- Mariko Noguchi-Sasaki
- Product Research Department, Chugai Pharmaceutical Co., Ltd., 200 Kajiwara, Kamakura, Kanagawa, 247-8530, Japan.
| | - Yusuke Sasaki
- Product Research Department, Chugai Pharmaceutical Co., Ltd., 200 Kajiwara, Kamakura, Kanagawa, 247-8530, Japan
| | - Yukari Matsuo-Tezuka
- Product Research Department, Chugai Pharmaceutical Co., Ltd., 200 Kajiwara, Kamakura, Kanagawa, 247-8530, Japan
| | - Hideyuki Yasuno
- Product Research Department, Chugai Pharmaceutical Co., Ltd., 200 Kajiwara, Kamakura, Kanagawa, 247-8530, Japan
| | - Mitsue Kurasawa
- Product Research Department, Chugai Pharmaceutical Co., Ltd., 200 Kajiwara, Kamakura, Kanagawa, 247-8530, Japan
| | - Keigo Yorozu
- Product Research Department, Chugai Pharmaceutical Co., Ltd., 200 Kajiwara, Kamakura, Kanagawa, 247-8530, Japan
| | - Yasushi Shimonaka
- Product Research Department, Chugai Pharmaceutical Co., Ltd., 200 Kajiwara, Kamakura, Kanagawa, 247-8530, Japan
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Del Vecchio L, Longhi S, Locatelli F. Safety concerns about intravenous iron therapy in patients with chronic kidney disease. Clin Kidney J 2016; 9:260-7. [PMID: 26985378 PMCID: PMC4792617 DOI: 10.1093/ckj/sfv142] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 11/20/2015] [Indexed: 01/12/2023] Open
Abstract
Anaemia in chronic kidney disease (CKD) is managed primarily with erythropoiesis-stimulating agents (ESAs) and iron therapy. Following concerns around ESA therapy, intravenous (IV) iron is being administered more and more worldwide. However, it is still unclear whether this approach is safe at very high doses or in the presence of very high ferritin levels. Some observational studies have shown a relationship between either high ferritin level or high iron dose and increased risk of death, cardiovascular events, hospitalization or infection. Others have not been able to confirm these findings. However, they suffer from indication biases. On the other hand, the majority of randomized clinical trials have only a very short follow-up (and thus drug exposure) and are inadequate to assess the mortality risk. None of them have tested the role of different iron doses on hard end points. With the lack of clear evidence coming from well-designed and large-scale studies, several data suggest that excessive iron therapy may be toxic in several aspects, ranging from iron overload to tissue damage from labile iron. A number of experimental and clinical data suggest that either excessive iron therapy or iron overload may be a possible culprit of atherogenesis. The process seems to be mediated by oxidative stress. Iron therapy should also be used cautiously in the presence of active infections, since iron is essential for bacterial growth. Recently, the European Medicines Agency officially raised concerns about rare hypersensitivity reactions following IV iron administration. The balance has been in favour of benefits. In several European countries, this has created a lot of confusion and somewhat slowed the run towards excessive use. Altogether, IV iron remains a mainstay of anaemia treatment in CKD patients. However, in our opinion, its excessive use should be avoided, especially in patients with high ferritin levels and when ESA agents are not contraindicated.
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Affiliation(s)
- Lucia Del Vecchio
- Department of Nephrology and Dialysis , A. Manzoni Hospital , Lecco , Italy
| | - Selena Longhi
- Department of Nephrology and Dialysis , A. Manzoni Hospital , Lecco , Italy
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Macdougall IC, Bircher AJ, Eckardt KU, Obrador GT, Pollock CA, Stenvinkel P, Swinkels DW, Wanner C, Weiss G, Chertow GM, Adamson JW, Akizawa T, Anker SD, Auerbach M, Bárány P, Besarab A, Bhandari S, Cabantchik I, Collins AJ, Coyne DW, de Francisco ÁL, Fishbane S, Gaillard CA, Ganz T, Goldsmith DJ, Hershko C, Jankowska EA, Johansen KL, Kalantar-Zadeh K, Kalra PA, Kasiske BL, Locatelli F, Małyszko J, Mayer G, McMahon LP, Mikhail A, Nemeth E, Pai AB, Parfrey PS, Pecoits-Filho R, Roger SD, Rostoker G, Rottembourg J, Singh AK, Slotki I, Spinowitz BS, Tarng DC, Tentori F, Toblli JE, Tsukamoto Y, Vaziri ND, Winkelmayer WC, Wheeler DC, Zakharova E. Iron management in chronic kidney disease: conclusions from a “Kidney Disease: Improving Global Outcomes” (KDIGO) Controversies Conference. Kidney Int 2016; 89:28-39. [DOI: 10.1016/j.kint.2015.10.002] [Citation(s) in RCA: 167] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 09/22/2015] [Accepted: 09/29/2015] [Indexed: 12/21/2022]
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Onuma S, Honda H, Kobayashi Y, Yamamoto T, Michihata T, Shibagaki K, Yuza T, Hirao K, Tomosugi N, Shibata T. Effects of Long-Term Erythropoiesis-Stimulating Agents on Iron Metabolism in Patients on Hemodialysis. Ther Apher Dial 2015; 19:582-9. [DOI: 10.1111/1744-9987.12322] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Shoko Onuma
- Division of Nephrology; Department of Medicine; Showa University, School of Medicine; Tokyo Japan
| | - Hirokazu Honda
- Division of Nephrology, Department of Medicine; Showa University Koto Toyosu Hospital; Tokyo Japan
| | - Yasuna Kobayashi
- Division of Clinical Pharmacy, Department of Pharmacotherapeutics; Showa University, School of Pharmacy; Tokyo Japan
| | - Toshinori Yamamoto
- Division of Clinical Pharmacy, Department of Pharmacotherapeutics; Showa University, School of Pharmacy; Tokyo Japan
| | | | - Keigo Shibagaki
- Division of Dialysis; Shibagaki Dialysis Clinic Jiyugaoka; Tokyo Japan
| | - Toshitaka Yuza
- Division of Dialysis; Shibagaki Dialysis Clinic Jiyugaoka; Tokyo Japan
| | - Keiichi Hirao
- Division of Dialysis; Shibagaki Dialysis Clinic Togoshi; Tokyo Japan
| | - Naohisa Tomosugi
- Aging Research Unit, Department of Advanced Medicine, Medical Research Institute; Kanazawa Medical University; Kanazawa Japan
| | - Takanori Shibata
- Division of Nephrology; Department of Medicine; Showa University, School of Medicine; Tokyo Japan
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Kali A, Yayar O, Erdogan B, Eser B, Buyukbakkal M, Ercan Z, Merhametsiz O, Haspulat A, Gök Oğuz E, Canbakan B, Ayli MD. Is hepcidin-25 a predictor of atherosclerosis in hemodialysis patients? Hemodial Int 2015; 20:191-7. [PMID: 26374145 DOI: 10.1111/hdi.12355] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Atherosclerotic cardiovascular disease is an important cause of mortality and morbidity in hemodialysis patients. Iron accumulation in arterial wall macrophages is increased in atherosclerotic lesions. Hepcidin is a key hepatic hormone regulating iron balance. It inhibits iron release from macrophages and iron absorption from enterocytes by binding and inactivating the cellular iron exporter ferroportin. The aim of this study is to investigate the relation of hepcidin-25, iron parameters, and atherosclerosis measured by carotid intima media thickness (CIMT) in hemodialysis patients. Eighty-two hemodialysis patients were enrolled in this cross-sectional study. Predialysis blood samples were centrifuged at 1500 g and 4°C for 10 minutes and stored at -80°C for the measurement of hepcidin-25. DRG hepcidin enzyme-linked immunosorbent assay kit was used for the measurement of hepcidin-25. Ultrasonographical B-mode imaging of bilateral carotid arteries was performed with a high-resolution real-time ultrasonography (Mindray DC7). Mean age of the study population was 57.90 ± 16.08 years and 43.9% were men. Total study population was grouped into two according to median value of hepcidin-25. There was no difference between groups with respect to age, dialysis vintage, and C-reactive protein. CIMT was found to be statistically significantly higher in low hepcidin-25 group. In correlation analysis, CIMT was found to be correlated with age (P < 0.01, R = 0.33) and hepcidin-25 (P < 0.01, R = 0.46). In linear regression analysis, age (β = 0.31) and hepcidin-25 (β = 0.44) were found to be the determinants of CIMT in hemodialysis patients. Our results implicate that hepcidin may take part in pathophysiology of atherosclerosis and cardiovascular disease in hemodialysis patients.
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Affiliation(s)
- Alaaddin Kali
- Department of Nephrology, Diskapi Yildirim Beyazid Research and Training Hospital, Ankara, Turkey
| | - Ozlem Yayar
- Department of Nephrology, Diskapi Yildirim Beyazid Research and Training Hospital, Ankara, Turkey
| | - Bulent Erdogan
- Department of Nephrology, Diskapi Yildirim Beyazid Research and Training Hospital, Ankara, Turkey
| | - Baris Eser
- Department of Nephrology, Diskapi Yildirim Beyazid Research and Training Hospital, Ankara, Turkey
| | - Mehmet Buyukbakkal
- Department of Nephrology, Diskapi Yildirim Beyazid Research and Training Hospital, Ankara, Turkey
| | - Zafer Ercan
- Department of Nephrology, Diskapi Yildirim Beyazid Research and Training Hospital, Ankara, Turkey
| | - Ozgur Merhametsiz
- Department of Nephrology, Diskapi Yildirim Beyazid Research and Training Hospital, Ankara, Turkey
| | - Ayhan Haspulat
- Department of Nephrology, Diskapi Yildirim Beyazid Research and Training Hospital, Ankara, Turkey
| | - Ebru Gök Oğuz
- Department of Nephrology, Diskapi Yildirim Beyazid Research and Training Hospital, Ankara, Turkey
| | - Basol Canbakan
- Department of Nephrology, Diskapi Yildirim Beyazid Research and Training Hospital, Ankara, Turkey
| | - Mehmet D Ayli
- Department of Nephrology, Diskapi Yildirim Beyazid Research and Training Hospital, Ankara, Turkey
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Iron Stores, Hepcidin, and Aortic Stiffness in Individuals with Hypertension. PLoS One 2015; 10:e0134635. [PMID: 26244503 PMCID: PMC4526526 DOI: 10.1371/journal.pone.0134635] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 07/11/2015] [Indexed: 11/19/2022] Open
Abstract
Background & Aims Iron accumulation within the arterial wall has been hypothesized to promote atherosclerosis progression. Aim of this study was to evaluate whether the hormone hepcidin and iron stores are associated with arterial stiffness in subjects with essential hypertension. Methods Circulating hepcidin, ferritin, and mutations in the hemochromatosis gene were compared between subjects included in the first vs. third tertile (n=284 each) of carotid-femoral pulse wave velocity (PWV) in an unselected cohort of patients with arterial hypertension. Results At univariate logistic regression analysis, high PWV was associated with higher ferritin levels (p=0.010), but lower hepcidin (p=0.045), and hepcidin ferritin/ratio (p<0.001). Hemochromatosis mutations predisposing to iron overload were associated with high PWV (p=0.025). At multivariate logistic regression analysis, high aortic stiffness was associated with older age, male sex, lower BMI, higher systolic blood pressure and heart rate, hyperferritinemia (OR 2.05, 95% c.i. 1.11-3.17 per log ng/ml; p=0.022), and lower circulating hepcidin concentration (OR 0.29, 95% c.i. 0.16-0.51 per log ng/ml; p<0.001). In subgroup analyses, high PWV was associated with indices of target organ damage, including micro-albuminuria (n=125, p=0.038), lower ejection fraction (n=175, p=0.031), cardiac diastolic dysfunction (p=0.004), and lower S wave peak systolic velocity (p<0.001). Ferritin was associated with cardiac diastolic dysfunction, independently of confounders (p=0.006). Conclusions In conclusion, hyperferritinemia is associated with high aortic stiffness and cardiac diastolic dysfunction, while low circulating hepcidin with high aortic stiffness.
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Kerkhoff AD, Meintjes G, Burton R, Vogt M, Wood R, Lawn SD. Relationship Between Blood Concentrations of Hepcidin and Anemia Severity, Mycobacterial Burden, and Mortality Among Patients With HIV-Associated Tuberculosis. J Infect Dis 2015; 213:61-70. [PMID: 26136467 PMCID: PMC4676545 DOI: 10.1093/infdis/jiv364] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 05/22/2015] [Indexed: 12/02/2022] Open
Abstract
Background Anemia is very common in patients with human immunodeficiency virus (HIV)–associated tuberculosis, and hepcidin may be key in mediating this. We explored the relationship between blood hepcidin concentrations and anemia severity, mycobacterial burden and mortality in patients with HIV-associated tuberculosis. Methods Consecutive unselected HIV-infected adults in South Africa were systematically investigated for tuberculosis. Three groups were studied: 116 hospitalized inpatients with HIV infection and tuberculosis (hereafter, “hospitalized patients”), 58 ambulatory outpatients with HIV infection and newly diagnosed tuberculosis (hereafter, “ambulatory patients with tuberculosis”), and 58 ambulatory outpatients with HIV infection and without tuberculosis (hereafter, “ambulatory patients without tuberculosis”). Blood hepcidin concentrations were determined for all patients. Vital status at 3 months was determined, and independent predictors of mortality were identified. Results Median hepcidin concentrations were 38.8 ng/mL among hospitalized patients, 19.1 ng/mL among ambulatory patients with tuberculosis, and 5.9 ng/mL among ambulatory patients without tuberculosis (P < .001). In both groups with HIV-associated tuberculosis, hepcidin concentrations were strongly associated with greater anemia severity. Additionally, strong, graded associations were observed between hepcidin and composite indices of mycobacterial burden and dissemination. Patients dying within 3 months had significantly higher hepcidin concentrations, which independently predicted mortality. Conclusions High hepcidin concentrations were strongly associated with disseminated disease, anemia, and poor prognosis in patients with HIV-associated tuberculosis. Hepcidin may be a mechanistically important mediator underlying the high prevalence of severe anemia in these patients.
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Affiliation(s)
- Andrew D Kerkhoff
- Department of Medicine, University of California San Francisco School of Medicine Department of Global Health, Academic Medical Center, Amsterdam Institute for Global Health and Development, University of Amsterdam, The Netherlands The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine
| | - Graeme Meintjes
- Department of Medicine, Faculty of Health Sciences Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town Department of Medicine, Imperial College
| | - Rosie Burton
- Department of Medicine, Khayelitsha District Hospital, Cape Town, South Africa
| | - Monica Vogt
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine
| | - Robin Wood
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Stephen D Lawn
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, United Kingdom
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Nistor I, Palmer SC, Craig JC, Saglimbene V, Vecchio M, Covic A, Strippoli GFM. Haemodiafiltration, haemofiltration and haemodialysis for end-stage kidney disease. Cochrane Database Syst Rev 2015; 2015:CD006258. [PMID: 25993563 PMCID: PMC10766139 DOI: 10.1002/14651858.cd006258.pub2] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Convective dialysis modalities (haemofiltration (HF), haemodiafiltration (HDF), and acetate-free biofiltration (AFB)) removed excess body fluid across the dialysis membrane with positive pressure and accumulated middle- and larger-size accumulated solutes more efficiently than haemodialysis (HD). This increased larger solute removal combined with use of ultra-pure dialysis fluid in convective dialysis is hypothesised to reduce the frequency and severity of symptoms during dialysis as well as improve clinical outcomes. Convective dialysis therapies (HDF and HF) are associated with lower mortality compared to diffusive therapy (HD) in observational studies. This is an update of a review first published in 2006. OBJECTIVES To compare convective (HF, HDF, or AFB) with diffusive (HD) dialysis modalities on clinical outcomes (mortality, major cardiovascular events, hospitalisation and treatment-related adverse events) in men and women with end-stage kidney disease (ESKD). SEARCH METHODS We searched the Cochrane Renal Group's Specialised Register (to 18 February 2015) through contact with a Trials' Search Co-ordinator using search terms relevant to this review. SELECTION CRITERIA We included randomised controlled trials comparing convective therapy (HF, HDF, AFB) with another convective therapy or diffusive therapy (HD) for treatment of ESKD. DATA COLLECTION AND ANALYSIS Two independent authors identified studies, extracted data and assessed study risk of bias. We summarised treatment effects using the random effects model. We reported results as a risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous data together with 95% confidence intervals (CI). We assessed for heterogeneity using the Chi(2) test and explored the amount of variation in treatment estimates beyond that expected by chance using the I(2) statistic. MAIN RESULTS Twenty studies comprising 667 participants were included in the 2006 review. In that review, there was insufficient evidence of treatment effects on major clinical outcomes to draw clinically meaningful conclusions. Searching to February 2015 identified 40 eligible studies comprising 3483 participants overall. In total, 35 studies (4039 participants) compared HF, HDF or AFB with HD, three studies (54 participants) compared AFB with HDF, and three studies (129 participants) compared HDF with HF.Risks of bias in all studies were generally high resulting in low confidence in estimated treatment effects. Convective dialysis had no significant effect on all-cause mortality (11 studies, 3396 participants: RR 0.87, 95% CI 0.72 to 1.05; I(2) = 34%), but significantly reduced cardiovascular mortality (6 studies, 2889 participants: RR 0.75, 95% CI 0.61 to 0.92; I(2) = 0%). One study reported no significant effect on rates of nonfatal cardiovascular events (714 participants: RR 1.14, 95% CI 0.86 to 1.50) and two studies showed no significant difference in hospitalisation (2 studies, 1688 participants: RR 1.23, 95% CI 0.93 to 1.63; I(2) = 0%). One study reported rates of hypotension during dialysis were significantly reduced with convective therapy (906 participants: RR 0.72, 95% CI 0.66 to 0.80). Adverse events were not systematically evaluated in most studies and data for health-related quality of life were sparse. Convective therapies significantly reduced predialysis levels of B2 microglobulin (12 studies, 1813 participants: MD -5.55 mg/dL, 95% CI -9.11 to -1.98; I(2) = 94%) and increased dialysis dose (Kt/V urea) (14 studies, 2022 participants: MD 0.07, 95% CI -0.00 to 0.14; I(2) = 90%) compared to diffusive therapy, but results across studies were very heterogeneous. Sensitivity analyses limited to studies comparing HDF with HD showed very similar results. Directly comparative data for differing types of convective dialysis were insufficient to draw conclusions.Studies had important risks of bias leading to low confidence in the summary estimates and were generally limited to patients who had adequate dialysis vascular access. AUTHORS' CONCLUSIONS Convective dialysis may reduce cardiovascular but not all-cause mortality and effects on nonfatal cardiovascular events and hospitalisation are inconclusive. However, any treatment benefits of convective dialysis on all patient outcomes including cardiovascular death are unreliable due to limitations in study methods and reporting. Future studies which assess treatment effects of convection dose on patient outcomes including mortality and cardiovascular events would be informative.
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Affiliation(s)
- Ionut Nistor
- "Gr. T. Popa" University of Medicine and PharmacyNephrology DepartmentBdul Carol I, No 50IasiIasiRomania700503
- Ghent University HospitalEuropean Renal Best Practice Methods Support TeamGhentBelgium
| | - Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Jonathan C Craig
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | - Valeria Saglimbene
- Mario Negri Sud ConsortiumClinical Pharmacology and EpidemiologyVia Nazionale 8/ASanta Maria ImbaroChietiItaly66030
| | - Mariacristina Vecchio
- Mario Negri Sud ConsortiumDepartment of Clinical Pharmacology and EpidemiologyVia Nazionale 8/ASanta Maria ImbaroChietiItaly66030
| | - Adrian Covic
- "Gr. T. Popa" University of Medicine and PharmacyNephrology DepartmentBdul Carol I, No 50IasiIasiRomania700503
| | - Giovanni FM Strippoli
- The Children’s Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchWestmeadAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- Diaverum Medical Scientific OfficeLundSweden
- Diaverum AcademyBariItaly
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50
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Li H, Feng SJ, Su LL, Wang W, Zhang XD, Wang SX. Serum hepcidin predicts uremic accelerated atherosclerosis in chronic hemodialysis patients with diabetic nephropathy. Chin Med J (Engl) 2015; 128:1351-7. [PMID: 25963357 PMCID: PMC4830316 DOI: 10.4103/0366-6999.156781] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Hepcidin, as a regulator of body iron stores, has been recently discovered to play a critical role in the pathogenesis of anemia of chronic disease. Atherosclerotic cardiovascular disease is the most common complication and the leading cause of death in chronic hemodialysis (CHD) patients. In the current study, we aimed to explore the relationship between serum hepcidin and uremic accelerated atherosclerosis (UAAS) in CHD patients with diabetic nephropathy (CHD/DN). METHODS A total of 78 CHD/DN and 86 chronic hemodialyzed nondiabetic patients with chronic glomerulonephritis (CHD/non-DN) were recruited in this study. The level of serum hepcidin-25 was specifically measured by liquid chromatography-tandem mass spectrometry. Serum levels of interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) were measured by enzyme-linked immunosorbent assay. RESULTS High serum level of hepcidin-25 was seen in CHD patients. Serum hepcidin-25 in CHD/DN was significantly higher than that in CHD/non-DN patients. Serum hepcidin-25 was positively correlated with ferritin, high-sensitivity C-reactive protein (hs-CRP), TNF-α, and IL-6 in CHD/DN patients. CHD/DN patients exhibited higher common carotid artery intima media thickness (CCA-IMT), hs-CRP, and hepcidin-25 levels than that in CHD/non-DN patients. Moreover, in CHD/DN patients, CCA-IMT was positively correlated with serum hepcidin, hs-CRP, and low-density lipoprotein-cholesterol. On multiple regression analysis, serum hepcidin and hs-CRP level exhibited independent association with IMT in CHD/DN patients. CONCLUSIONS These findings suggest possible linkage between iron metabolism and hepcidin modulation abnormalities that may contribute to the development of UAAS in CHD/DN patients.
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Affiliation(s)
- Han Li
- Department of Blood Purification, Beijing Chao-Yang Hospital, Capital Medical University; Nephrology Faculty, Capital Medical University, Beijng 100020, China
- Institute of Uro-Nephrology, Beijing Chao-Yang Hospital, Capital Medical University, Beijng 100020, China
| | - Su-Juan Feng
- Department of Blood Purification, Beijing Chao-Yang Hospital, Capital Medical University; Nephrology Faculty, Capital Medical University, Beijng 100020, China
- Institute of Uro-Nephrology, Beijing Chao-Yang Hospital, Capital Medical University, Beijng 100020, China
| | - Lu-Lu Su
- Institute of Uro-Nephrology, Beijing Chao-Yang Hospital, Capital Medical University, Beijng 100020, China
| | - Wei Wang
- Institute of Uro-Nephrology, Beijing Chao-Yang Hospital, Capital Medical University, Beijng 100020, China
| | - Xiao-Dong Zhang
- Institute of Uro-Nephrology, Beijing Chao-Yang Hospital, Capital Medical University, Beijng 100020, China
| | - Shi-Xiang Wang
- Department of Blood Purification, Beijing Chao-Yang Hospital, Capital Medical University; Nephrology Faculty, Capital Medical University, Beijng 100020, China
- Institute of Uro-Nephrology, Beijing Chao-Yang Hospital, Capital Medical University, Beijng 100020, China
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