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Cernaro V, Longhitano E, Casuscelli C, Peritore L, Santoro D. Hyperphosphatemia in Chronic Kidney Disease: The Search for New Treatment Paradigms and the Role of Tenapanor. Int J Nephrol Renovasc Dis 2024; 17:151-161. [PMID: 38831770 PMCID: PMC11144652 DOI: 10.2147/ijnrd.s385826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 05/14/2024] [Indexed: 06/05/2024] Open
Abstract
Hyperphosphataemia represents a significant challenge in the management of chronic kidney disease, exerting a pronounced influence on the pathogenesis of cardiovascular complications and mineral bone disorders. Traditional approaches to address hyperphosphataemia involve implementing dietary phosphate restrictions, administering phosphate binders, and, in cases of end-stage renal disease, resorting to dialysis. Unfortunately, these interventions frequently prove inadequate in maintaining phosphate levels within recommended ranges. Additionally, commonly employed pharmacological agents are not immune to eliciting adverse events, thereby limiting their prescription and therapeutic adherence. There is a growing focus on exploring novel therapeutic strategies in this context. The current discussion centres on tenapanor, a pharmacological agent predominantly acting as a selective inhibitor of sodium/hydrogen exchanger isoform 3 (NHE3). Its mechanism of action involves modulating tight junctions, resulting in reduced sodium absorption and intestinal paracellular permeability to phosphate. Furthermore, tenapanor downregulates sodium-dependent phosphate 2b transport protein (NaPi2b) expression, thereby impeding active transcellular phosphate transport. Clinical trials have elucidated the efficacy and safety profile of tenapanor. This evidence hints at a potential paradigm shift in the management of hyperphosphataemia. However, the burgeoning optimism surrounding tenapanor warrants tempered enthusiasm, as further research remains indispensable. The imperative lies in meticulously delineating its efficacy and safety contours within the crucible of clinical practice. In this review, we synthesize the intricate interplay between hyperphosphataemia and Chronic Kidney Disease-Mineral Bone Disorder, and we discuss the existing pharmacological interventions for hyperphosphataemia and explore emerging treatment paradigms that offer novel perspectives in managing elevated phosphate levels in CKD patients.
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Affiliation(s)
- Valeria Cernaro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Elisa Longhitano
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Chiara Casuscelli
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Luigi Peritore
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Domenico Santoro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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Abstract
Inorganic phosphate (Pi) is an essential component of many biologically important molecules such as DNA, RNA, ATP, phospholipids, or apatite. It is required for intracellular phosphorylation signaling events and acts as pH buffer in intra- and extracellular compartments. Intestinal absorption, uptake into cells, and renal reabsorption depend on a set of different phosphate transporters from the SLC20 (PiT transporters) and SLC34 (NaPi transporters) gene families. The physiological relevance of these transporters is evident from rare monogenic disorders in humans affecting SLC20A2 (Fahr's disease, basal ganglia calcification), SLC34A1 (idiopathic infantile hypercalcemia), SLC34A2 (pulmonary alveolar microlithiasis), and SLC34A3 (hereditary hypophosphatemic rickets with hypercalciuria). SLC34 transporters are inhibited by millimolar concentrations of phosphonoformic acid or arsenate while SLC20 are relatively resistant to these compounds. More recently, a series of more specific and potent drugs have been developed to target SLC34A2 to reduce intestinal Pi absorption and to inhibit SLC34A1 and/or SLC34A3 to increase renal Pi excretion in patients with renal disease and incipient hyperphosphatemia. Also, SLC20 inhibitors have been developed with the same intention. Some of these substances are currently undergoing preclinical and clinical testing. Tenapanor, a non-absorbable Na+/H+-exchanger isoform 3 inhibitor, reduces intestinal Pi absorption likely by indirectly acting on the paracellular pathway for Pi and has been tested in several phase III trials for reducing Pi overload in patients with renal insufficiency and dialysis.
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Affiliation(s)
- Carsten A Wagner
- Institute of Physiology, University of Zurich, Zurich, Switzerland.
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Gao L, Huang X, Deng R, Wu S, Peng Y, Xiong G, Lu J, Liu X. Jian-Pi-Yi-Shen formula alleviates renal fibrosis by restoring NAD+ biosynthesis in vivo and in vitro. Aging (Albany NY) 2023; 16:106-128. [PMID: 38157259 PMCID: PMC10817388 DOI: 10.18632/aging.205352] [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: 05/30/2023] [Accepted: 11/15/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) lack efficacious treatment. Jian-Pi-Yi-Shen formula (JPYSF) has demonstrated significant clinical efficacy in treating CKD for decades. However, its renoprotective mechanism has not been fully elucidated. This study aimed to determine whether JPYSF could delay renal fibrosis progression in CKD by restoring nicotinamide adenine dinucleotide (NAD+) biosynthesis. METHODS Adenine-diet feeding was used to model CKD in C57BL/6 mice. JPYSF was orally administered for 4 weeks. Human proximal tubular epithelial cells (HK-2) cells were stimulated with transforming growth factor-β1 (TGF-β1) with or without JPYSF treatment. Renal function of mice was assessed by serum creatinine and blood urea nitrogen levels. Renal histopathological changes were assessed using Periodic acid-Schiff and Masson's trichrome staining. Cell viability was assessed using a cell counting kit-8 assay. NAD+ concentrations were detected by a NAD+/NADH assay kit. Western blotting, immunohistochemistry, and immunofluorescence were employed to examine fibrosis-related proteins and key NAD+ biosynthesis enzymes expression in the CKD kidney and TGF-β1-induced HK-2 cells. RESULTS JPYSF treatment could not only improve renal function and pathological injury but also inhibit renal fibrosis in CKD mice. Additionally, JPYSF reversed fibrotic response in TGF-β1-induced HK-2 cells. Moreover, JPYSF rescued the decreased NAD+ content in CKD mice and TGF-β1-induced HK-2 cells through restoring expression of key enzymes in NAD+ biosynthesis, including quinolinate phosphoribosyltransferase, nicotinamide mononucleotide adenylyltransferase 1, and nicotinamide riboside kinase 1. CONCLUSIONS JPYSF alleviated renal fibrosis in CKD mice and reversed fibrotic response in TGF-β1-induced HK-2 cells, which may be related to the restoration of NAD+ biosynthesis.
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Affiliation(s)
- Liwen Gao
- Department of Nephrology, Shenzhen Traditional Chinese Medicine Hospital, Guangzhou University of Chinese Medicine, Shenzhen, Guangdong 518033, China
- The Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, Guangdong 518033, China
| | - Xi Huang
- Department of Nephrology, Shenzhen Traditional Chinese Medicine Hospital, Guangzhou University of Chinese Medicine, Shenzhen, Guangdong 518033, China
- The Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, Guangdong 518033, China
| | - Ruyu Deng
- Department of Nephrology, Shenzhen Traditional Chinese Medicine Hospital, Guangzhou University of Chinese Medicine, Shenzhen, Guangdong 518033, China
- Shenzhen Traditional Chinese Medicine Hospital Affiliated to Nanjing University of Chinese Medicine, Shenzhen, Guangdong 518033, China
| | - Shanshan Wu
- Department of Nephrology, Shenzhen Traditional Chinese Medicine Hospital, Guangzhou University of Chinese Medicine, Shenzhen, Guangdong 518033, China
- The Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, Guangdong 518033, China
| | - Yu Peng
- Department of Nephrology, Shenzhen Traditional Chinese Medicine Hospital, Guangzhou University of Chinese Medicine, Shenzhen, Guangdong 518033, China
- The Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, Guangdong 518033, China
| | - Guoliang Xiong
- Department of Nephrology, Shenzhen Traditional Chinese Medicine Hospital, Guangzhou University of Chinese Medicine, Shenzhen, Guangdong 518033, China
| | - Jiandong Lu
- Department of Nephrology, Shenzhen Traditional Chinese Medicine Hospital, Guangzhou University of Chinese Medicine, Shenzhen, Guangdong 518033, China
| | - Xinhui Liu
- Department of Nephrology, Shenzhen Traditional Chinese Medicine Hospital, Guangzhou University of Chinese Medicine, Shenzhen, Guangdong 518033, China
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Yoshimura N, Yamada K, Ono T, Notoya M, Yukioka H, Takahashi R, Wakino S, Kanda T, Itoh H. N-methyl-2-pyridone-5-carboxamide (N-Me-2PY) has potent anti-fibrotic and anti-inflammatory activity in a fibrotic kidney model: is it an old uremic toxin? Clin Exp Nephrol 2023; 27:901-911. [PMID: 37490135 DOI: 10.1007/s10157-023-02379-1] [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: 12/25/2022] [Accepted: 07/07/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Uremic toxins accumulate in renal tissues and cells due to chronic kidney disease (CKD). Abnormalities in nicotinamide adenine dinucleotide (NAD +) metabolism lead to the progression of CKD. NAD + metabolites, such as N-methyl-2-pyridone-5-carboxamide (N-Me-2PY) and N-methyl-4-pyridone-5-carboxamide (N-Me-4PY), have been recognized as uremic toxins. However, no reports have validated whether they are actually harmful to the body. Therefore, we focused on the structural similarity of these metabolites to the anti-fibrotic drug pirfenidone and evaluated their effects on renal fibrosis. METHODS Each NAD + metabolite was treated with TGFβ1 to kidney fibroblasts or tubular epithelial cells, and quantitative RT-PCR and Western blot analysis were conducted. N-Me-2PY was orally administered to a ligated murine kidney fibrosis model (UUO) to evaluate its anti-fibrotic and toxic effects on the body. RESULTS N-Me-2PY, N-Me-4PY, and nicotinamide N-oxide (NNO) inhibited TGFβ1-induced fibrosis and inflammatory gene expression in kidney fibroblasts. N-Me-2PY strongly suppressed the expression of types I and III collagen, αSMA, and IL-6. N-Me-2PY also suppressed TGFβ1-induced type I collagen and IL-6 expression in renal tubular epithelial cells. No toxic effect was observed with N-Me-2PY treatment, while attenuating renal fibrosis and tubular dilation in UUO mice. Suppression of various fibrosis- and inflammation-related genes was also observed. N-Me-2PY did not inhibit TGFβ1-induced Smad3 phosphorylation but inhibited Akt phosphorylation, suggesting that N-Me-2PY exerts anti-fibrotic and anti-inflammatory effects through Akt inhibition, similar to pirfenidone. CONCLUSIONS NAD + metabolites, such as N-Me-2PY, are not uremic toxins but are potential therapeutic agents that have anti-fibrotic effects in CKD.
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Affiliation(s)
- Norito Yoshimura
- Drug Discovery & Disease Research Laboratory, Shionogi & Co., Ltd., Osaka, Japan
- School of Medicine, Keio University, Tokyo, Japan
| | - Katsutoshi Yamada
- Drug Discovery & Disease Research Laboratory, Shionogi & Co., Ltd., Osaka, Japan
| | - Takashi Ono
- Drug Discovery & Disease Research Laboratory, Shionogi & Co., Ltd., Osaka, Japan
| | - Mitsuru Notoya
- Drug Discovery & Disease Research Laboratory, Shionogi & Co., Ltd., Osaka, Japan
| | - Hideo Yukioka
- Drug Discovery & Disease Research Laboratory, Shionogi & Co., Ltd., Osaka, Japan
| | | | - Shu Wakino
- Department of Nephrology, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Takeshi Kanda
- School of Medicine, Keio University, Tokyo, Japan.
- Division of Nephrology, Shimane University Hospital, 89-1,Enya-Cho, Izumo-Shi, Shimane, 693-8501, Japan.
| | - Hiroshi Itoh
- School of Medicine, Keio University, Tokyo, Japan
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Song Q, Zhou X, Xu K, Liu S, Zhu X, Yang J. The Safety and Antiaging Effects of Nicotinamide Mononucleotide in Human Clinical Trials: an Update. Adv Nutr 2023; 14:1416-1435. [PMID: 37619764 PMCID: PMC10721522 DOI: 10.1016/j.advnut.2023.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 08/02/2023] [Accepted: 08/15/2023] [Indexed: 08/26/2023] Open
Abstract
The importance of nicotinamide adenine dinucleotide (NAD+) in human physiology is well recognized. As the NAD+ concentration in human skin, blood, liver, muscle, and brain are thought to decrease with age, finding ways to increase NAD+ status could possibly influence the aging process and associated metabolic sequelae. Nicotinamide mononucleotide (NMN) is a precursor for NAD+ biosynthesis, and in vitro/in vivo studies have demonstrated that NMN supplementation increases NAD+ concentration and could mitigate aging-related disorders such as oxidative stress, DNA damage, neurodegeneration, and inflammatory responses. The promotion of NMN as an antiaging health supplement has gained popularity due to such findings; however, since most studies evaluating the effects of NMN have been conducted in cell or animal models, a concern remains regarding the safety and physiological effects of NMN supplementation in the human population. Nonetheless, a dozen human clinical trials with NMN supplementation are currently underway. This review summarizes the current progress of these trials and NMN/NAD+ biology to clarify the potential effects of NMN supplementation and to shed light on future study directions.
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Affiliation(s)
- Qin Song
- Department of Occupational and Environmental Health, Hangzhou Normal University School of Public Health, Hangzhou, China
| | - Xiaofeng Zhou
- Department of Radiotherapy, The 2(nd) Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Kexin Xu
- Department of Nutritional and Toxicological Science, Hangzhou Normal University School of Public Health, Hangzhou, China
| | - Sishi Liu
- Department of Nutritional and Toxicological Science, Hangzhou Normal University School of Public Health, Hangzhou, China
| | - Xinqiang Zhu
- Core Facility, The 4(th) Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, China.
| | - Jun Yang
- Department of Nutritional and Toxicological Science, Hangzhou Normal University School of Public Health, Hangzhou, China; Zhejiang Provincial Center for Uterine Cancer Diagnosis and Therapy Research, The Affiliated Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China.
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Magagnoli L, Cozzolino M, Galassi A. The open system of FGF-23 at the crossroad between additional P-lowering therapy, anemia and inflammation: how to deal with the intact and the C-terminal assays? Clin Kidney J 2023; 16:1543-1549. [PMID: 37779858 PMCID: PMC10539210 DOI: 10.1093/ckj/sfad144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Indexed: 10/03/2023] Open
Abstract
Fibroblast growth factor 23 (FGF-23) has been associated with increased cardiovascular risk and poor survival in dialysis patients. It is well established that FGF-23 synthesis is directly induced by positive phosphate (P) balance. On the other hand, P-lowering treatments such as nutritional P restriction, P binders and dialysis are capable of reducing FGF-23 levels. However, there are many uncertainties regarding the possibility of adopting FGF-23 to guide the clinical decision-making process in the context of chronic kidney disease-mineral bone disorder (CKD-MBD). Furthermore, the best assay to adopt for measurement of FGF-23 levels (namely the intact vs the C-terminal one) remains to be determined, especially in conditions capable of altering the synthesis as well as the cleavage of the intact and biologically active molecule, as occurs in the presence of CKD and its complications. This Editorial discusses the main insights provided by the post hoc analysis of the NOPHOS trial, with particular attention given to evidence-based peculiarities of the intact and the C-terminal assays available for measuring FGF-23 levels, especially in patients receiving additive P-lowering therapy in the presence of inflammation, anemia and iron deficiency.
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Affiliation(s)
- Lorenza Magagnoli
- University of Milan, Department of Health Sciences, Milano, Italy
- ASST Santi Paolo e Carlo, Renal Division, Milano, Italy
| | - Mario Cozzolino
- University of Milan, Department of Health Sciences, Milano, Italy
- ASST Santi Paolo e Carlo, Renal Division, Milano, Italy
| | - Andrea Galassi
- University of Milan, Department of Health Sciences, Milano, Italy
- ASST Santi Paolo e Carlo, Renal Division, Milano, Italy
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Wu HHL, McDonnell T, Chinnadurai R. Physiological Associations between Vitamin B Deficiency and Diabetic Kidney Disease. Biomedicines 2023; 11:biomedicines11041153. [PMID: 37189771 DOI: 10.3390/biomedicines11041153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 03/24/2023] [Accepted: 04/10/2023] [Indexed: 05/17/2023] Open
Abstract
The number of people living with chronic kidney disease (CKD) is growing as our global population continues to expand. With aging, diabetes, and cardiovascular disease being major harbingers of kidney disease, the number of people diagnosed with diabetic kidney disease (DKD) has grown concurrently. Poor clinical outcomes in DKD could be influenced by an array of factors-inadequate glycemic control, obesity, metabolic acidosis, anemia, cellular senescence, infection and inflammation, cognitive impairment, reduced physical exercise threshold, and, importantly, malnutrition contributing to protein-energy wasting, sarcopenia, and frailty. Amongst the various causes of malnutrition in DKD, the metabolic mechanisms of vitamin B (B1 (Thiamine), B2 (Riboflavin), B3 (Niacin/Nicotinamide), B5 (Pantothenic Acid), B6 (Pyridoxine), B8 (Biotin), B9 (Folate), and B12 (Cobalamin)) deficiency and its clinical impact has garnered greater scientific interest over the past decade. There remains extensive debate on the biochemical intricacies of vitamin B metabolic pathways and how their deficiencies may affect the development of CKD, diabetes, and subsequently DKD, and vice-versa. Our article provides a review of updated evidence on the biochemical and physiological properties of the vitamin B sub-forms in normal states, and how vitamin B deficiency and defects in their metabolic pathways may influence CKD/DKD pathophysiology, and in reverse how CKD/DKD progression may affect vitamin B metabolism. We hope our article increases awareness of vitamin B deficiency in DKD and the complex physiological associations that exist between vitamin B deficiency, diabetes, and CKD. Further research efforts are needed going forward to address the knowledge gaps on this topic.
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Affiliation(s)
- Henry H L Wu
- Renal Research Laboratory, Kolling Institute of Medical Research, Royal North Shore Hospital, The University of Sydney, Sydney, NSW 2065, Australia
| | - Thomas McDonnell
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK
| | - Rajkumar Chinnadurai
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK
- Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M1 7HR, UK
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NAD + Metabolism and Interventions in Premature Renal Aging and Chronic Kidney Disease. Cells 2022; 12:cells12010021. [PMID: 36611814 PMCID: PMC9818486 DOI: 10.3390/cells12010021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/17/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Premature aging causes morphological and functional changes in the kidney, leading to chronic kidney disease (CKD). CKD is a global public health issue with far-reaching consequences, including cardio-vascular complications, increased frailty, shortened lifespan and a heightened risk of kidney failure. Dialysis or transplantation are lifesaving therapies, but they can also be debilitating. Currently, no cure is available for CKD, despite ongoing efforts to identify clinical biomarkers of premature renal aging and molecular pathways of disease progression. Kidney proximal tubular epithelial cells (PTECs) have high energy demand, and disruption of their energy homeostasis has been linked to the progression of kidney disease. Consequently, metabolic reprogramming of PTECs is gaining interest as a therapeutic tool. Preclinical and clinical evidence is emerging that NAD+ homeostasis, crucial for PTECs' oxidative metabolism, is impaired in CKD, and administration of dietary NAD+ precursors could have a prophylactic role against age-related kidney disease. This review describes the biology of NAD+ in the kidney, including its precursors and cellular roles, and discusses the importance of NAD+ homeostasis for renal health. Furthermore, we provide a comprehensive summary of preclinical and clinical studies aimed at increasing NAD+ levels in premature renal aging and CKD.
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Sodium phosphate cotransporter 2a inhibitors: potential therapeutic uses. Curr Opin Nephrol Hypertens 2022; 31:486-492. [PMID: 35894284 PMCID: PMC9387751 DOI: 10.1097/mnh.0000000000000828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Targeting sodium phosphate cotransporter 2a (Npt2a) offers a novel strategy for treating hyperphosphatemia in chronic kidney disease (CKD). Here we review recent studies on the efficacy of Npt2a inhibition, its plasma phosphate (Pi)-lowering effects, as well as potential "off-target" beneficial effects on cardiovascular consequences. RECENT FINDINGS Two novel Npt2a-selective inhibitors (PF-06869206 and BAY-767) have been developed. Pharmacological Npt2a inhibition shows a significant phosphaturic effect and consequently lowers plasma Pi and parathyroid hormone (PTH) levels regardless of CKD. However, plasma fibroblast growth factor 23 (FGF23), a master regulator of Pi homeostasis, shows inconsistent responses between these two inhibitors (no effect by PF-06869206 vs. reduction by BAY-767). In addition to the effects on Pi homeostasis, Npt2a inhibition also enhances urinary excretions of Na+, Cl-, and Ca2+, which is recapitulated in animal models with reduced kidney function. The effect of Npt2a inhibition by BAY-767 on vascular calcification has been studied, with positive results showing that oral treatment with BAY-767 (10 mg kg-1) attenuated the increases in plasma Pi and Ca2+ content in the aorta under the setting of vascular calcification induced by a pan-FGF receptor inhibitor. Together, Npt2a inhibition offers a promising therapeutic approach for treating hyperphosphatemia and reducing cardiovascular complications in CKD. SUMMARY Npt2a inhibition significantly increases urinary Pi excretion and lowers plasma Pi and PTH levels; moreover, it exerts pleiotropic "off-target" effects, providing a novel treatment for hyperphosphatemia and exhibiting beneficial potential for cardiovascular complications in CKD.
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Phosphate Frustration: Treatment Options to Complement Current Therapies. Int J Nephrol 2022; 2022:9457440. [PMID: 36045900 PMCID: PMC9424003 DOI: 10.1155/2022/9457440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 07/16/2022] [Indexed: 11/18/2022] Open
Abstract
Hyperphosphatemia eventually develops in almost all patients with advanced chronic kidney disease and is associated with negative clinical outcomes. Thus, guidelines recommend targeting treatment to normal phosphate levels in patients with chronic kidney disease. Despite low phosphorus diets, clearance by dialysis, and phosphate binder use, many patients with chronic kidney disease on dialysis are unable to consistently achieve and maintain serum phosphate concentrations <5.5 mg/dL. A chart audit of patients on dialysis receiving phosphate binders showed that 74 to 86% were unable to consistently achieve serum phosphate ≤5.5 mg/dL over 6 months. Furthermore, although there is evidence that serum phosphate concentrations <4.5 mg/dL are associated with improved survival and cardiovascular outcomes, real-world phosphate control data suggest achieving and maintaining this goal for most patients would be extremely challenging, if not near impossible, using current therapies. As phosphate binders can only remove approximately 300 mg of the 2,500 mg or more daily dietary phosphate intake, therapeutic innovations are necessary to improve phosphate management. We present treatment options to complement current therapies including tenapanor, a novel sodium/hydrogen exchanger isoform 3 inhibitor that blocks the dominant paracellular phosphate absorption pathway and has been shown to reduce phosphate levels in several clinical trials.
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11
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Duque EJ, Elias RM, Moysés RMA. Phosphate balance during dialysis and after kidney transplantation in patients with chronic kidney disease. Curr Opin Nephrol Hypertens 2022; 31:326-331. [PMID: 35703226 DOI: 10.1097/mnh.0000000000000802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW In patients with chronic kidney disease (CKD), hyperphosphatemia is associated with several adverse outcomes, including bone fragility and progression of kidney and cardiovascular disease. However, there is a knowledge gap regarding phosphate balance in CKD. This review explores its current state, depending on the stage of CKD, dialysis modalities, and the influence of kidney transplantation. RECENT FINDINGS Adequate phosphate control is one of the goals of treatment for CKD-mineral and bone disorder. However, ongoing studies are challenging the benefits of phosphate-lowering treatment. Nevertheless, the current therapy is based on dietary restriction, phosphate binders, and optimal removal by dialysis. In the face of limited adherence, due to the high pill burden, adjuvant options are under investigation. The recent discovery that intestinal absorption of phosphate is mostly paracellular when the intraluminal concentration is adequate might help explain why phosphate is still well absorbed in CKD, despite the lower levels of calcitriol. SUMMARY Future studies could confirm the benefits of phosphate control. Greater understanding of the complex distribution of phosphate among the body compartments will help us define a better therapeutic strategy in patients with CKD.
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Affiliation(s)
- Eduardo J Duque
- Laboratorio de Fisiopatologia Renal LIM16, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo
| | - Rosilene M Elias
- Laboratorio de Fisiopatologia Renal LIM16, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo
- Postgraduate Program in Medicine, Nove de Julho University, São Paulo, SP, Brazil
| | - Rosa M A Moysés
- Laboratorio de Fisiopatologia Renal LIM16, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo
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12
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Ketteler M, Wiecek A, Rosenkranz AR, Ose C, Rekowski J, Lorenz H, Hellmann B, Karus M, Ruhmann M, Ammer R. Modified-release nicotinamide for the treatment of hyperphosphataemia in haemodialysis patients: 52-week efficacy and safety results of the phase III randomised controlled NOPHOS trial. Nephrol Dial Transplant 2022; 38:982-991. [PMID: 35751625 PMCID: PMC10064978 DOI: 10.1093/ndt/gfac206] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We previously reported that modified-release nicotinamide (NAMR) was superior to placebo in reducing serum phosphate concentrations over 12 weeks in a large cohort of haemodialysis patients with hyperphosphataemia. Here, we report outcomes after 52 weeks of treatment. METHODS NOPHOS was a phase III, international, randomised, controlled, double-blind trial in parallel group design. NAMR (250-1500 mg/d) was investigated in comparison to placebo as an add-on therapy to an individual therapy with approved phosphate binders. RESULTS In the intention-to-treat population (NAMR: N = 539, placebo: N = 183), serum phosphate was significantly lower in the NAMR group compared to the placebo group at W24 (5.40 ± 1.55 mg/dl vs. 5.79 ± 1.37 mg/dl, P < 0.001) with a mean difference of -0.39 mg/dl [95% CI -0.66, -0.13], but was comparable between the groups at W52 (mean difference -0.08 [95% CI -0.36, 0.20]). In the completer population (N = 358), statistical significance in favour of NAMR was reached at W24 and W52. The treatment effect was reduced in patients with high baseline serum intact parathyroid hormone (iPTH) compared to patients with low baseline serum iPTH. Compliant patients in the NAMR group had a more pronounced and sustained reduction in serum phosphate than non-compliant patients. NAMR treatment was associated with a significantly increased risk of thrombocytopenia, pruritus, anaemia, and diarrhoea. Herpes zoster occurred exclusively in patients randomised to NAMR. CONCLUSIONS NAMR combined with phosphate binders significantly reduced serum phosphate over the first 24 weeks of treatment, but the treatment effect was not maintained up to W52. Non-compliance may have contributed to reduced long-term efficacy. Several newly identified safety signals warrant further evaluation.
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Affiliation(s)
- Markus Ketteler
- Robert Bosch Hospital, Department of General Internal Medicine and Nephrology, Stuttgart,Germany.,University of Split, School of Medicine, Split, Croatia
| | - Andrzej Wiecek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia in Katowice, Poland
| | - Alexander R Rosenkranz
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Claudia Ose
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany.,Center for Clinical Trials, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Jan Rekowski
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany.,Center for Clinical Trials, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Horst Lorenz
- BBS-Büro für Biometrie und Statistik, Neuberg, Germany
| | - Burkhard Hellmann
- Medical Department, MEDICE Arzneimittel Pütter GmbH & Co. KG, Iserlohn, Germany
| | - Michael Karus
- Medical Department, MEDICE Arzneimittel Pütter GmbH & Co. KG, Iserlohn, Germany
| | - Michaela Ruhmann
- Medical Department, MEDICE Arzneimittel Pütter GmbH & Co. KG, Iserlohn, Germany
| | - Richard Ammer
- Medical Department, MEDICE Arzneimittel Pütter GmbH & Co. KG, Iserlohn, Germany.,Department of Nephrology, University Hospital Münster, Münster, Germany
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13
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Mainville L, Smilga AS, Fortin PR. Effect of Nicotinamide in Skin Cancer and Actinic Keratoses Chemoprophylaxis, and Adverse Effects Related to Nicotinamide: A Systematic Review and Meta-Analysis. J Cutan Med Surg 2022; 26:297-308. [PMID: 35134311 PMCID: PMC9125143 DOI: 10.1177/12034754221078201] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Oral nicotinamide is recommended in individuals with a field of cancerization or with ≥1 previous cutaneous squamous cell carcinoma (cSCC). OBJECTIVE To evaluate the effect of nicotinamide in prevention of skin cancers. METHODS We conducted a systematic review and meta-analysis of randomized controlled trials to evaluate the effect of nicotinamide. We used Medline, EMBASE, CENTRAL, and Web of Science databases from their inception to October 2020 to search the following concepts: "nicotinamide"; "randomized controlled trial" (validated filters). Two independent reviewers screened titles and abstracts for intervention and study design before searching full texts for eligibility criteria. To be eligible, ≥1 outcome had to be covered. We used a standardized collection grid to complete data extraction in duplicate. The primary outcome was skin cancers (all types). Secondary outcomes were basal cell carcinomas (BCCs); cSCCs; actinic keratoses; melanomas; digestive, cutaneous, and biochemical adverse effects (AEs). Subgroup analyses were planned a priori. RESULTS We screened 4730 citations and found 29 trials (3039 patients) meeting inclusion criteria. Nicotinamide was associated with a significant reduction in skin cancers compared to control (rate ratio 0.50 (95% CI, 0.29-0.85; I 2 = 64%; 552 patients; 5 trials); moderate strength of the evidence). Heterogeneity was explained by risk of bias. Nicotinamide was associated with a significant reduction in BCCs and cSCCs, and increased risk of digestive AEs. CONCLUSION Oral nicotinamide should be considered in healthy patients or organ transplant recipients with history of skin cancer (GRADE: weak recommendation; moderate-quality evidence), in particular of BCC and cSCC.
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Affiliation(s)
| | | | - Paul R. Fortin
- Infectious and Immune Diseases, Centre de recherche du CHU de Québec – Université Laval, Quebec, Canada
- Division of Rheumatology, Department of Medicine, CHU de Québec – Université Laval, Quebec, Canada
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14
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What If Not All Metabolites from the Uremic Toxin Generating Pathways Are Toxic? A Hypothesis. Toxins (Basel) 2022; 14:toxins14030221. [PMID: 35324718 PMCID: PMC8953523 DOI: 10.3390/toxins14030221] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/02/2022] [Accepted: 03/14/2022] [Indexed: 12/21/2022] Open
Abstract
The topic of uremic toxicity has received broad attention from the nephrological community over the past few decades. An aspect that is much less often considered is the possibility that the metabolic pathways that generate uremic toxins also may produce molecules that benefit body functions. Here, we discuss this dualism based on the example of tryptophan-derived metabolites, which comprise elements that are mainly toxic, such as indoxyl sulfate, kynurenine and kynurenic acid, but also beneficial compounds, such as indole, melatonin and indole-3-propionic acid, and ambivalent (beneficial for some aspects and harmful for others) compounds such as serotonin. This dualism can also be perceived at the level of the main receptor of the tryptophan-derived metabolites, the aryl hydrocarbon receptor (AHR), which has also been linked to both harm and benefit. We hypothesize that these beneficial effects are the reason why uremic toxin generation remained preserved throughout evolution. This duality is also not unique for the tryptophan-derived metabolites, and in this broader context we discuss the remote sensing and signaling theory (RSST). The RSST proposes that transporters (e.g., organic anion transporter 1—OAT1; ATP-binding cassette transporter G—ABCG2) and drug metabolizing enzymes form a large network of proteins interacting to promote small molecule remote communication at the inter-organ (e.g., gut–liver–heart–brain–kidney) and inter-organismal (e.g., gut microbe–host) levels. These small molecules include gut microbe-derived uremic toxins as well as beneficial molecules such as those discussed here. We emphasize that this positive side of uremic metabolite production needs more attention, and that this dualism especially needs to be considered when assessing and conceiving of therapeutic interventions. These homeostatic considerations are central to the RSST and suggest that interventions be aimed at preserving or restoring the balance between positive and negative components rather than eliminating them all without distinction.
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15
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Fontecha-Barriuso M, Lopez-Diaz AM, Carriazo S, Ortiz A, Sanz AB. Nicotinamide and acute kidney injury. Clin Kidney J 2021; 14:2453-2462. [PMID: 34950458 PMCID: PMC8690056 DOI: 10.1093/ckj/sfab173] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 08/09/2021] [Indexed: 12/12/2022] Open
Abstract
In a recent issue of ckj, Piedrafita et al. reported that urine tryptophan and kynurenine are reduced in cardiac bypass surgery patients that develop acute kidney injury (AKI), suggesting reduced activity of the kynurenine pathway of nicotinamide (NAM) adenine dinucleotide (NAD+) synthesis from tryptophan. However, NAM supplementation aiming at repleting NAD+ did not replete kidney NAD+ and did not improve glomerular filtration or reduce histological injury in ischaemic-reperfusion kidney injury in mice. The lack of improvement of kidney injury is partially at odds with prior reports that did not study kidney NAD+, glomerular filtration or histology in NAM-treated wild-type mice with AKI. We now present an overview of research on therapy with vitamin B3 vitamers and derivate molecules {niacin, Nicotinamide [NAM; niacinamide], NAM riboside [Nicotinamide riboside (NR)], Reduced nicotinamide riboside [NRH] and NAM mononucleotide} in kidney injury, including an overview of ongoing clinical trials, and discuss the potential explanations for diverging reports on the impact of these therapeutic approaches on pre-clinical acute and chronic kidney disease.
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Affiliation(s)
- Miguel Fontecha-Barriuso
- Laboratory of Experimental Nephrology, Research Institute-Fundacion Jimenez Diaz, Universidad Autonoma de Madrid, 28040 Madrid, Spain
- REDINREN, Madrid, Spain
| | - Ana M Lopez-Diaz
- Laboratory of Experimental Nephrology, Research Institute-Fundacion Jimenez Diaz, Universidad Autonoma de Madrid, 28040 Madrid, Spain
| | - Sol Carriazo
- Laboratory of Experimental Nephrology, Research Institute-Fundacion Jimenez Diaz, Universidad Autonoma de Madrid, 28040 Madrid, Spain
| | - Alberto Ortiz
- Laboratory of Experimental Nephrology, Research Institute-Fundacion Jimenez Diaz, Universidad Autonoma de Madrid, 28040 Madrid, Spain
- REDINREN, Madrid, Spain
- Department of Medicine, Universidad Autónoma de Madrid, 28049 Madrid, Spain
- IRSIN, Madrid, Spain
| | - Ana Belen Sanz
- Laboratory of Experimental Nephrology, Research Institute-Fundacion Jimenez Diaz, Universidad Autonoma de Madrid, 28040 Madrid, Spain
- REDINREN, Madrid, Spain
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16
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McCullough PA. Phosphate Control: The Next Frontier in Dialysis Cardiovascular Mortality. Cardiorenal Med 2021; 11:123-132. [PMID: 34120113 DOI: 10.1159/000516286] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 03/24/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cardiovascular disease (CVD) is a major cause of death in patients with chronic kidney disease (CKD) on dialysis. Mortality rates are still unacceptably high even though they have fallen in the past 2 decades. Hyperphosphatemia (elevated serum phosphate levels) is seen in almost all patients with advanced CKD and is by far the largest remaining modifiable contributor to CKD mortality. SUMMARY Phosphate retention drives multiple physiological mechanisms linked to increased risk of CVD. Fibroblast growth factor 23 and parathyroid hormone (PTH) levels, both of which have been suggested to have direct pathogenic CV effects, increase in response to phosphate retention. Phosphate, calcium, and PTH levels are linked in a progressively worsening cycle. Maladaptive upregulation of phosphate absorption is also likely to occur further exacerbating hyperphosphatemia. Even higher phosphate levels within the normal range may be a risk factor for vascular calcification and, thus, CV morbidity and mortality. A greater degree of phosphate control is important to reduce the risk of CV morbidity and mortality. Improved phosphate control and regular monitoring of phosphate levels are guideline-recommended, established clinical practices. There are several challenges with the current phosphate management approaches in patients with CKD on dialysis. Dietary restriction of phosphate and thrice-weekly dialysis alone are insufficient/unreliable to reduce phosphate to <5.5 mg/dL. Even with the addition of phosphate binders, the only pharmacological treatment currently indicated for hyperphosphatemia, the majority of patients are unable to achieve and maintain phosphate levels <5.5 mg/dL (or more normal levels) [PhosLo® gelcaps (calcium acetate): 667 mg (prescribing information), 2011, VELPHORO®: (Sucroferric oxyhydroxide) (prescribing information), 2013, FOSRENAL®: (Lanthanum carbonate) (prescribing information), 2016, AURYXIA®: (Ferric citrate) tablets (prescribing information), 2017, RENVELA®: (Sevelamer carbonate) (prescribing information), 2020, RealWorld dynamix. Dialysis US: Spherix Global Insights, 2019]. Phosphate binders do not target the primary pathway of phosphate absorption (paracellular), have limited binding capacity, and bind nonspecifically [PhosLo® gelcaps (calcium acetate): 667 mg (prescribing information). 2013, VELPHORO®: (Sucroferric oxyhydroxide) (prescribing information), 2013, FOSRENAL®: (Lanthanum carbonate) (prescribing information), 2016, AURYXIA®: (Ferric citrate) tablets (prescribing information), 2017, RENVELA®: (Sevelamer carbonate) (prescribing information) 2020]. Key Messages: Despite current phosphate management strategies, most patients on dialysis are unable to consistently achieve target phosphate levels, indicating a need for therapeutic innovations [RealWorld dynamix. Dialysis US: Spherix Global Insights, 2019]. Given a growing evidence base that the dominant mechanism of phosphate absorption is the intestinal paracellular pathway, new therapies are investigating ways to reduce phosphate levels by blocking absorption through the paracellular pathway.
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Affiliation(s)
- Peter A McCullough
- Baylor University Medical Center, Dallas, Texas, USA.,Department of Internal Medicine, Texas A & M College of Medicine, Baylor Heart and Vascular Institute, Dallas, Texas, USA.,Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas, USA
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17
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Lenglet A, Rahali MA, Sauvage FL, Liabeuf S, Choukroun G, Essig M, El Balkhi S, Massy ZA. Effect of Sevelamer and Nicotinamide on Albumin Carbamylation in Patients with End-Stage Kidney Disease. Drugs R D 2021; 21:231-238. [PMID: 34101139 PMCID: PMC8206311 DOI: 10.1007/s40268-021-00350-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2021] [Indexed: 11/24/2022] Open
Abstract
Background and Objective In end-stage kidney disease, high urea levels promote the carbamylation of lysine side chains on a variety of proteins, including albumin. Albumin carbamylation has been identified as a risk factor for mortality and sevelamer led to a decrease in urea levels in dialysis patients. In the present secondary analysis of the NICOREN trial, we investigated the putative impacts of sevelamer and nicotinamide on albumin carbamylation, and the potential correlation between carbamylation and vascular calcifications. Methods All possible carbamylation of circulating albumin were screened for with high-resolution liquid chromatography-tandem mass spectrometry. Levels of three carbamylated peptides were then measured as a guide to the extent of albumin carbamylation. Carbamylation was measured at baseline in 55 patients included in the NICOREN trial and 29 patients at 24 weeks of treatment. Calcifications on plain radiographs were quantified as the Kauppila score and the Adragao score. Results Baseline albumin carbamylation was present at three different sites in subjects with end-stage kidney disease. At baseline, we observed only a correlation between urea and the KQTA carbamylation site in these patients. Albumin carbamylation levels did not decrease after 24 weeks of treatment with either sevelamer or nicotinamide. Furthermore, the proportion of carbamylated serum albumin was not correlated with vascular calcification scores in this population. Conclusions Our results confirmed the presence of carbamylated albumin in patients with end-stage kidney disease and demonstrated the presence of carbamylation beyond the LRVP residues. The results also demonstrated the lack of impact of sevelamer or nicotinamide on albumin carbamylation levels. Therapeutic strategies to lower carbamylation load should probably be focused on direct anti-carbamylation processes and/or potentially anti-inflammatory therapies. Supplementary Information The online version contains supplementary material available at 10.1007/s40268-021-00350-7.
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Affiliation(s)
- Aurelie Lenglet
- EA7517, MP3CV Laboratory, CURS, Faculty of Pharmacy, Jules Verne University of Picardie, Amiens, France.,Pharmacy, Amiens University Hospital, Amiens, France
| | | | | | - Sophie Liabeuf
- EA7517, MP3CV Laboratory, CURS, Faculty of Pharmacy, Jules Verne University of Picardie, Amiens, France.,Division of Pharmacology, Amiens University Hospital, Amiens, France
| | - Gabriel Choukroun
- EA7517, MP3CV Laboratory, CURS, Faculty of Pharmacy, Jules Verne University of Picardie, Amiens, France.,Department of Nephrology Dialysis and Transplantation, Amiens University Hospital, Amiens, France
| | - Marie Essig
- INSERM U-1018, Centre de Recherche en Épidémiologie et Santé des Populations (CESP), Paris-Saclay University (PSU), University of Paris Ouest-Versailles-Saint-Quentin-en-Yvelines (UVSQ), Equipe 5, Villejuif, Paris, France.,Division of Nephrology, Ambroise Paré Hospital, Paris Ile de France Ouest University, 9 Avenue Charles de Gaulle, 92104, Boulogne Billancourt Cedex, France
| | - Souleiman El Balkhi
- INSERM, IPPRITT, U1248, Limoges, France.,Department of Pharmacology, Toxicology and Pharmacovigilance, CHU Limoges, Limoges, France
| | - Ziad A Massy
- INSERM U-1018, Centre de Recherche en Épidémiologie et Santé des Populations (CESP), Paris-Saclay University (PSU), University of Paris Ouest-Versailles-Saint-Quentin-en-Yvelines (UVSQ), Equipe 5, Villejuif, Paris, France. .,Division of Nephrology, Ambroise Paré Hospital, Paris Ile de France Ouest University, 9 Avenue Charles de Gaulle, 92104, Boulogne Billancourt Cedex, France.
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18
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Apetrii M, Covic A. Targeting NaPi-IIb for Hyperphosphatemia in Chronic Kidney Disease Patients - The Dead End? Kidney Int Rep 2021; 6:557-558. [PMID: 33735330 PMCID: PMC7938199 DOI: 10.1016/j.ekir.2021.01.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Mugurel Apetrii
- Nephrology Department, University of Medicine and Pharmacy, “Grigore T. Popa,” Iasi, Romania
| | - Adrian Covic
- Nephrology Department, University of Medicine and Pharmacy, “Grigore T. Popa,” Iasi, Romania
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19
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Ketteler M, Wiecek A, Rosenkranz AR, Pasch A, Rekowski J, Hellmann B, Karus M, Ammer R. Efficacy and Safety of a Novel Nicotinamide Modified-Release Formulation in the Treatment of Refractory Hyperphosphatemia in Patients Receiving Hemodialysis-A Randomized Clinical Trial. Kidney Int Rep 2021; 6:594-604. [PMID: 33732974 PMCID: PMC7938065 DOI: 10.1016/j.ekir.2020.12.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 12/08/2020] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Despite widespread use of phosphate binders (PBs), phosphate control is insufficient in many hemodialysis patients. Preliminary clinical observations suggest that nicotinamide may act synergistically with PBs to improve phosphate control. METHODS This multinational, randomized, double-blind, placebo-controlled study evaluated the efficacy and safety of nicotinamide modified release (NAMR) in combination with oral PB in a large cohort of hemodialysis patients with abnormal serum phosphate concentration (>4.5 mg/dl) despite treatment with PB. Patients entered a proof-of-efficacy phase (12 weeks [W12]) in which adjustments of relevant comedication were not permitted, followed by a safety extension phase for up to 52 weeks. Here, we report the results of the first phase. RESULTS The intention-to-treat (ITT) population consisted of 539 patients in the NAMR and 183 patients in the placebo group. NAMR and placebo were orally administered once daily (250-1500 mg/d). Mean age of patients was 61.8 years, and 63.0% were men. In the confirmatory analysis that estimated the difference in serum phosphate concentration after 12 weeks, NAMR proved superior over placebo with a significant difference of -0.51 mg/dl (95% confidence interval [CI] -0.72, -0.29; P < 0.0001). This effect was associated with significantly lower intact parathyroid hormone (iPTH) values (NAMR: 292.4±300.4 pg/ml vs. placebo: 337.0±302.7 pg/ml; P = 0.04) and an improved calcification propensity (T50 time; NAMR: 23.8±97.1 minutes vs. placebo: 2.3±100.7 minutes; P = 0.02). Diarrhea and pruritus were more frequent in the NAMR group. CONCLUSION NAMR combined with oral PB significantly improved phosphate control in hemodialysis patients.
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Affiliation(s)
- Markus Ketteler
- Robert Bosch Hospital, Department of General Internal Medicine and Nephrology, Stuttgart, Germany
- University of Split, School of Medicine, Split, Croatia
| | - Andrzej Wiecek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia in Katowice, Poland
| | - Alexander R. Rosenkranz
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Andreas Pasch
- Calciscon AG, Nidau, Switzerland
- Institute of Physiology and Pathophysiology, Johannes Kepler University Linz, Linz, Austria
- Nierenpraxis Bern, Bern, Switzerland
- Department of Nephrology, Lindenhofspital, Bern, Switzerland
| | - Jan Rekowski
- Institute for Medical Informatics, Biometry and Epidemiology, Essen University Hospital, Essen, Germany
- Center for Clinical Studies, University Hospital Essen, Essen, Germany
| | - Burkhard Hellmann
- Medical Department, MEDICE Arzneimittel Pütter GmbH & Co KG, Iserlohn, Germany
| | - Michael Karus
- Medical Department, MEDICE Arzneimittel Pütter GmbH & Co KG, Iserlohn, Germany
| | - Richard Ammer
- Medical Department, MEDICE Arzneimittel Pütter GmbH & Co KG, Iserlohn, Germany
- Department of Nephrology, University Hospital Münster, Münster, Germany
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Simultaneous management of disordered phosphate and iron homeostasis to correct fibroblast growth factor 23 and associated outcomes in chronic kidney disease. Curr Opin Nephrol Hypertens 2021; 29:359-366. [PMID: 32452919 DOI: 10.1097/mnh.0000000000000614] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Hyperphosphatemia, iron deficiency, and anemia are powerful stimuli of fibroblast growth factor 23 (FGF23) production and are highly prevalent complications of chronic kidney disease (CKD). In this manuscript, we put in perspective the newest insights on FGF23 regulation by iron and phosphate and their effects on CKD progression and associated outcomes. We especially focus on new studies aiming to reduce FGF23 levels, and we present new data that suggest major benefits of combined corrections of iron, phosphate, and FGF23 in CKD. RECENT FINDINGS New studies show that simultaneously correcting iron deficiency and hyperphosphatemia in CKD reduces the magnitude of FGF23 increase. Promising therapies using iron-based phosphate binders in CKD might mitigate cardiac and renal injury and improve survival. SUMMARY New strategies to lower FGF23 have emerged, and we discuss their benefits and risks in the context of CKD. Novel clinical and preclinical studies highlight the effects of phosphate restriction and iron repletion on FGF23 regulation.
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21
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Maruyama S, Marbury TC, Connaire J, Ries D, Maxwell W, Rambaran C. NaPi-IIb Inhibition for Hyperphosphatemia in CKD Hemodialysis Patients. Kidney Int Rep 2020; 6:675-684. [PMID: 33732982 PMCID: PMC7938184 DOI: 10.1016/j.ekir.2020.12.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/10/2020] [Accepted: 12/15/2020] [Indexed: 12/16/2022] Open
Abstract
Introduction Chronic kidney disease (CKD) has a prevalence of 9.1% globally, and frequently results in elevated serum phosphate, increasing cardiovascular morbidity and mortality risk in hemodialysis (HD) patients. DS-2330b, an oral NaPi-IIb inhibitor, reduced intestinal phosphate absorption in preclinical studies, but its effect in patients with CKD is unknown. This 2-part, randomized, placebo- and active-controlled, single- and repeated-dose, phase 1b study evaluated safety and efficacy of DS-2330b in patients with CKD on HD. Methods Part A, a 2-period, 2-way study, evaluated safety and pharmacokinetics of DS-2330b 250 mg in solution and tablet formulations. Part B assessed the safety of DS-2330b in solution (chosen based on results of part A) and its effect on serum phosphate. Patients were randomized to placebo 3 times daily (TID), DS-2330b 400 mg TID, DS-2330b 400 mg with sevelamer 1.6 g TID, and sevelamer 1.6 g with placebo TID for 14 days. Safety endpoints included adverse event (AE) monitoring. Results Six patients completed part A. Two patients experienced serious AEs considered unrelated to DS-2330b treatment. Thirty-two patients enrolled and completed part B. Serum phosphate mean change from baseline ± SD was −2.2±1.5 mg/dl versus −1.9 ± 1.1 mg/dl for DS-2330b monotherapy versus placebo. Patients receiving DS-2330b with sevelamer or sevelamer with placebo experienced the greatest serum phosphate decrease from baseline. Nine patients (28.1%) experienced ≥1 treatment-emergent AE (TEAE); 7 patients experienced drug-related TEAEs. The TEAE incidence was comparable between DS-2330b and control groups. Conclusions DS-2330b, alone or in combination with sevelamer, was safe and well tolerated but did not demonstrate clinically meaningful efficacy in HD patients.
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Affiliation(s)
| | | | | | - Daniel Ries
- Kidney Specialists of Minnesota, Minneapolis, Minnesota, USA
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22
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Kaesler N, Goettsch C, Weis D, Schurgers L, Hellmann B, Floege J, Kramann R. Magnesium but not nicotinamide prevents vascular calcification in experimental uraemia. Nephrol Dial Transplant 2020; 35:65-73. [PMID: 30715488 DOI: 10.1093/ndt/gfy410] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 12/13/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Optimal phosphate control is an unmet need in chronic kidney disease (CKD). High serum phosphate increases calcification burden and is associated with mortality and cardiovascular disease in CKD. Nicotinamide (NA) alone or in combination with calcium-free phosphate binders might be a strategy to reduce phosphate levels and calcification and thus impact cardiovascular disease in CKD. METHODS We studied the effect of NA alone and in combination with magnesium carbonate (MgCO3) as a potential novel treatment strategy. CKD was induced in dilute brown non-agouti/2 mice by subtotal nephrectomy followed by a high-phosphate diet (HP) and 7 weeks of treatment with NA, MgCO3 or their combination. Control mice underwent subtotal nephrectomy and received an HP or underwent sham surgery and received standard chow plus NA. RESULTS CKD mice showed increased serum fibroblast growth factor 23 and calcium-phosphate product that was normalized by all treatment regimes. NA alone increased soft tissue and vascular calcification, whereas any treatment with MgCO3 significantly reduced calcification severity in CKD. While MgCO3 supplementation alone resulted in decreased calcification severity, it resulted in increased intestinal expression of the phosphate transporters type II sodium-dependent phosphate transporter 1 (Pit-1). Combined therapy of MgCO3 and NA reduced tissue calcification and normalized expression levels of intestinal phosphate transporter proteins. CONCLUSIONS In conclusion, the data indicate that NA increases while MgCO3 reduces ectopic calcification severity. Augmented expression of intestinal phosphate transporters by MgCO3 treatment was abolished by the addition of NA. However, the clinical relevance of the latter remains to be explored. Importantly, the data suggest no benefit of NA regarding treatment of calcification in addition to MgCO3.
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Affiliation(s)
- Nadine Kaesler
- Department of Nephrology, University Hospital of the RWTH Aachen, Aachen, Germany
| | - Claudia Goettsch
- Department of Cardiology, University Hospital of the RWTH Aachen, Aachen, Germany
| | - Daniel Weis
- Department of Nephrology, University Hospital of the RWTH Aachen, Aachen, Germany
| | - Leon Schurgers
- Department of Nephrology, University Hospital of the RWTH Aachen, Aachen, Germany.,Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | | | - Jürgen Floege
- Department of Nephrology, University Hospital of the RWTH Aachen, Aachen, Germany
| | - Rafael Kramann
- Department of Nephrology, University Hospital of the RWTH Aachen, Aachen, Germany.,Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
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23
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Hwang ES, Song SB. Possible Adverse Effects of High-Dose Nicotinamide: Mechanisms and Safety Assessment. Biomolecules 2020; 10:biom10050687. [PMID: 32365524 PMCID: PMC7277745 DOI: 10.3390/biom10050687] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/20/2020] [Accepted: 04/21/2020] [Indexed: 12/21/2022] Open
Abstract
Nicotinamide (NAM) at doses far above those recommended for vitamins is suggested to be effective against a wide spectrum of diseases and conditions, including neurological dysfunctions, depression and other psychological disorders, and inflammatory diseases. Recent increases in public awareness on possible pro-longevity effects of nicotinamide adenine dinucleotide (NAD+) precursors have caused further growth of NAM consumption not only for clinical treatments, but also as a dietary supplement, raising concerns on the safety of its long-term use. However, possible adverse effects and their mechanisms are poorly understood. High-level NAM administration can exert negative effects through multiple routes. For example, NAM by itself inhibits poly(ADP-ribose) polymerases (PARPs), which protect genome integrity. Elevation of the NAD+ pool alters cellular energy metabolism. Meanwhile, high-level NAM alters cellular methyl metabolism and affects methylation of DNA and proteins, leading to changes in cellular transcriptome and proteome. Also, methyl metabolites of NAM, namely methylnicotinamide, are predicted to play roles in certain diseases and conditions. In this review, a collective literature search was performed to provide a comprehensive list of possible adverse effects of NAM and to provide understanding of their underlying mechanisms and assessment of the raised safety concerns. Our review assures safety in current usage level of NAM, but also finds potential risks for epigenetic alterations associated with chronic use of NAM at high doses. It also suggests directions of the future studies to ensure safer application of NAM.
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Tsuboi Y, Ohtomo S, Ichida Y, Hagita H, Ozawa K, Iida M, Nagao S, Ikegami H, Takahashi T, Horiba N. EOS789, a novel pan-phosphate transporter inhibitor, is effective for the treatment of chronic kidney disease-mineral bone disorder. Kidney Int 2020; 98:343-354. [PMID: 32624180 DOI: 10.1016/j.kint.2020.02.040] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 02/18/2020] [Accepted: 02/28/2020] [Indexed: 12/13/2022]
Abstract
Chronic kidney disease is characterized as impaired renal function along with the imbalance and dysregulation of mineral metabolism; recognized as chronic kidney disease-mineral and bone disorder. Hyperphosphatemia, characterized by altered phosphate homeostasis along with elevated fibroblast growth factor-23 and intact parathyroid hormone, is such an alteration of mineral metabolism. We discovered a novel inhibitor, EOS789, that interacts with several sodium-dependent phosphate transporters (NaPi-IIb, PiT-1, and PiT-2) known to contribute to intestinal phosphate absorption. This inhibitor dose-dependently increased the fecal phosphorus excretion rate and inversely decreased the urinary phosphorus excretion rate in normal rats, suggesting inhibition of intestinal phosphorus absorption. In rats with adenine-induced hyperphosphatemia, EOS789 markedly decreased the serum phosphate, fibroblast growth factor-23, and intact parathyroid hormone below values found in normal control rats. Notably, this pan-phosphate transporter inhibitor exhibited a more potent effect on serum phosphate than a NaPi-IIb-selective inhibitor in rats with hyperphosphatemia indicating that PiT-1 and PiT-2 play important roles in intestinal phosphate absorption. Moreover, in a long-term study, EOS789 sustained the suppression of serum phosphorus in parallel with fibroblast growth factor-23 and intact parathyroid hormone and ameliorated ectopic calcification of the thoracic aorta. Additionally, EOS789 treatment also ameliorated kidney deterioration in rats with progressive kidney injury, probably due to the strict phosphate control. Thus, EOS789 has potent efficacy against hyperphosphatemia and its complications and could provide a significant benefit to patients who are ineffectively treated with phosphate binders.
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Affiliation(s)
- Yoshinori Tsuboi
- Research Division, Chugai Pharmaceutical Co., Ltd., Gotemba, Shizuoka, Japan
| | - Shuichi Ohtomo
- Research Division, Chugai Pharmaceutical Co., Ltd., Gotemba, Shizuoka, Japan.
| | - Yasuhiro Ichida
- Research Division, Chugai Pharmaceutical Co., Ltd., Gotemba, Shizuoka, Japan
| | - Hitoshi Hagita
- Chugai Research Institute for Medical Science, Inc., Gotemba, Shizuoka, Japan
| | - Kazuharu Ozawa
- Research Division, Chugai Pharmaceutical Co., Ltd., Gotemba, Shizuoka, Japan
| | - Manami Iida
- Research Division, Chugai Pharmaceutical Co., Ltd., Gotemba, Shizuoka, Japan
| | - Shunsuke Nagao
- Translational Research Division, Chugai Pharmaceutical Co., Ltd., Kamakura, Kanagawa, Japan
| | - Hisashi Ikegami
- Translational Research Division, Chugai Pharmaceutical Co., Ltd., Kamakura, Kanagawa, Japan
| | - Tadakatsu Takahashi
- Research Division, Chugai Pharmaceutical Co., Ltd., Gotemba, Shizuoka, Japan
| | - Naoshi Horiba
- Research Division, Chugai Pharmaceutical Co., Ltd., Gotemba, Shizuoka, Japan
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25
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Drüeke TB, Massy ZA. Vascular calcification-any place left for nicotinamide? Nephrol Dial Transplant 2020; 35:18-22. [PMID: 31071218 DOI: 10.1093/ndt/gfz057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 03/06/2019] [Indexed: 12/12/2022] Open
Affiliation(s)
- Tilman B Drüeke
- Inserm U-1018, Team 5, CESP, Versailles Saint-Quentin-en-Yvelines University (Paris-Ile-de-France-Ouest University, UVSQ), Paris-Sud University (UPS), and Paris Saclay University, Villejuif, France
| | - Ziad A Massy
- Inserm U-1018, Team 5, CESP, Versailles Saint-Quentin-en-Yvelines University (Paris-Ile-de-France-Ouest University, UVSQ), Paris-Sud University (UPS), and Paris Saclay University, Villejuif, France.,Division of Nephrology, Ambroise Paré Hospital, APHP, Boulogne-Billancourt, Paris, France
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26
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Cozzolino M, Ketteler M, Wagner CA. An expert update on novel therapeutic targets for hyperphosphatemia in chronic kidney disease: preclinical and clinical innovations. Expert Opin Ther Targets 2020; 24:477-488. [PMID: 32191548 DOI: 10.1080/14728222.2020.1743680] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: The management of hyperphosphatemia in patients with chronic kidney disease (CKD) is complicated, requiring a multidisciplinary approach that includes dietary phosphate restriction, dialysis, and phosphate binders.Areas covered: We describe key players involved in regulating inorganic phosphate homeostasis and their differential role in healthy people and different stages of CKD. The contribution of paracellular and transcellular intestinal absorptive mechanisms are also examined. Finally, we illuminate recent therapeutic approaches for hyperphosphatemia in CKD. We searched PubMed/Medline (up to November 2019) using the following terms: chronic kidney disease, dialysis, diet, hyperphosphatemia, NaPi2b, nicotinamide, phosphate binder, secondary hyperparathyroidism, tenapanor and vascular calcification.Expert opinion: The precise mechanisms regulating intestinal phosphate absorption in humans is not completely understood. However, it is now established that this process involves two independent pathways: a) active transport (i.e. transcellular route, via specific ion transporters) and inactive transport (i.e. paracellular route across tight junctions). Dietary phosphate restriction and phosphate-binder use can lead to an undesirable maladaptive increase in phosphate uptake and promote active phosphate transport by increased expression of the gastrointestinal sodium-dependent phosphate transporter, NaPi2b. Nicotinamide may overcome these limitations through the inhibition of NaPi2b, by improved efficacy and reduced phosphate binder use and better compliance.
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Affiliation(s)
- Mario Cozzolino
- Renal Division, ASST Santi Paolo E Carlo, Department of Health Sciences, University of Milan, Milan, Italy
| | - Markus Ketteler
- Department of General Internal Medicine and Nephrology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Carsten Alexander Wagner
- Institute of Physiology, University of Zurich, Zurich, Switzerland.,National Center of Competence in Research, NCCR Kidney. CH, Zurich, Switzerland
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27
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Floege J. Phosphate binders in chronic kidney disease: an updated narrative review of recent data. J Nephrol 2019; 33:497-508. [PMID: 31865608 DOI: 10.1007/s40620-019-00689-w] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 12/17/2019] [Indexed: 12/11/2022]
Abstract
Chronic kidney disease (CKD) is frequently accompanied by hyperphosphatemia. High serum phosphate usually requires dietary measures, adequate dialysis prescription and/or phosphate binders. For this narrative review a PubMed searched was undertaken to identify new publications on phosphate binders that had been published between January 2015 and July 2019. The present review summarizes this most recent information on dietary measures and their problems in treating hyperphosphatemia in CKD patients, overall effects of phosphate binders on cardiovascular mortality and morbidity, adherence to phosphate binder therapy as well as new data on specific aspects of the various phosphate binders on the market: calcium-containing phosphate binders, polymeric phosphate binders (sevelamer, bixalomer, colestilan), magnesium-containing phosphate binders, lanthanum carbonate, ferric citrate, sucroferric oxyhydroxide, and new compounds in development, in particular drugs targeting intestinal phosphate transporters.
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Affiliation(s)
- Jürgen Floege
- Department of Nephrology and Clinical Immunology, University Hospital, Rheinisch Westfälische Technische Hochschule (RWTH), Pauwelsstr. 30, 52057, Aachen, Germany.
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28
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Role of Nicotinamide in Genomic Stability and Skin Cancer Chemoprevention. Int J Mol Sci 2019; 20:ijms20235946. [PMID: 31779194 PMCID: PMC6929077 DOI: 10.3390/ijms20235946] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 11/16/2019] [Accepted: 11/23/2019] [Indexed: 12/16/2022] Open
Abstract
Nicotinamide (NAM) is an amide form of vitamin B3 and the precursor of nicotinamide adenine dinucleotide (NAD+), an essential co-enzyme of redox reactions for adenosine triphosphate (ATP) production and for other metabolic processes. As NAD+ status is critical in maintaining cellular energy, vitamin B3 deficiency mainly affects tissues that need high cellular energy causing pellagra and skin sun sensitivity. In animal models, NAD+ deficiency leads to UV sensitivity of the skin, impairs DNA damage response, and increases genomic instability and cancer incidence. Furthermore, NAD+ depletion is associated with human skin aging and cancer. NAM prevents the UV-induced ATP depletion boosting cellular energy and enhances DNA repair activity in vitro and in vivo. Moreover, NAM reduces skin cancer incidence and prevents the immune-suppressive effects of UV in mice. Thus, NAM is involved in the maintenance of genomic stability and may have beneficial effects against skin aging changes and tumor development. Clinical studies showed that topical use of NAM reduces cutaneous aging. Furthermore, oral NAM administration reduces the level of UV-mediated immunosuppression and lowers the rate of non-melanoma skin cancers in high-risk patients. Therefore, NAM replenishment strategy may be a promising approach for skin cancer chemoprevention.
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29
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Massy ZA, Liabeuf S. From old uraemic toxins to new uraemic toxins: place of 'omics'. Nephrol Dial Transplant 2019; 33:iii2-iii5. [PMID: 30281133 PMCID: PMC6168884 DOI: 10.1093/ndt/gfy212] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 06/07/2018] [Indexed: 01/17/2023] Open
Abstract
Uraemic toxins seem to play an important role in the genesis of cardiovascular and renal damage in chronic kidney disease patients. This short article is divided into two thematic sections. The first part focuses on a selection of ‘old’ toxins for which recent data (published between 2016 and 2018) have provided a better understanding of the associated harmful mechanisms and which, in our opinion, nephrologists should be more aware of. The second part highlights new perspectives for identifying and quantifying these compounds using ‘omics’ techniques.
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Affiliation(s)
- Ziad A Massy
- Division of Nephrology, Ambroise Paré Hospital, Paris Ile-de-France Ouest University (UVSQ), Boulogne Billancourt, France.,INSERM Unit-1018, CESP, University Paris-Saclay, University of Versailles-Saint-Quentin-en-Yvelines, Université Paris Sud, Villejuif, France
| | - Sophie Liabeuf
- Clinical Research Department, Division of Clinical Pharmacology, Amiens University Hospital, Amiens, France.,INSERM U1088, Jules Verne University of Picardie, Amiens, France
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30
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Does the Administration of Sevelamer or Nicotinamide Modify Uremic Toxins or Endotoxemia in Chronic Hemodialysis Patients? Drugs 2019; 79:855-862. [PMID: 31062264 DOI: 10.1007/s40265-019-01118-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Hyperphosphatemia control is a major issue in hemodialysis patients. Both sevelamer and nicotinamide are prescribed for this purpose. In addition, they exert pleiotropic effects such as an improvement of inflammatory status and potentially enhanced clearance of uremic toxins. In the present secondary analysis of the NICOREN trial, we investigated the impact of sevelamer and nicotinamide on uremic toxins, toxin precursors, and endotoxemia in chronic hemodialysis patients. METHODS Circulating uremic toxins (including phenylacetylglutamine, trimethylamine-N-oxide, p-cresyl sulfate, indoxyl sulfate, kynurenine, hippuric acid, indole-3-acetic acid, 3-carboxy-4-methyl-5-propyl-2-furanpropionic acid, kynurenic acid, and p-cresyl glucuronide) and precursors were measured by ultra-performance liquid chromatography-tandem mass spectrometry, and urea, uric acid, phosphate, C-reactive protein, and intact parathyroid hormone by routine biochemistry methods. Serum endotoxin (evaluated by lipopolysaccharide levels) and C-terminal fibroblast growth factor-23 levels were measured using enzyme-linked immunosorbent assay kits. RESULTS One hundred hemodialysis patients were randomized to receive either nicotinamide or sevelamer treatment. Among them, 63% were male, mean (± standard deviation) age was 65 ± 14 years, 47% had diabetes mellitus, and 51% had a history of cardiovascular disease. In the sevelamer group, but not the nicotinamide group, serum levels of urea, uric acid, and fibroblast growth factor-23 were significantly reduced after 6 months of treatment. The other circulating uremic toxins and toxin precursors remained unchanged in response to either phosphate-lowering agent. Sevelamer treatment led to a marked decrease in serum lipopolysaccharide (p < 0.001) whereas nicotinamide treatment induced an only modest decrease of borderline significance (p = 0.057). There was no change in C-reactive protein levels. CONCLUSION In contrast to sevelamer, nicotinamide did not reduce circulating levels of low-molecular-weight uremic toxins other than phosphate, and neither agent reduced circulating uremic toxins of high-molecular-weight or protein-bound toxins. Sevelamer, but not nicotinamide, reduced serum endotoxin levels. Despite no change in serum C-reactive protein, the endotoxin-lowering effect of sevelamer may help to attenuate the inflammatory status of patients with chronic kidney disease.
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31
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Barreto FC, Barreto DV, Massy ZA, Drüeke TB. Strategies for Phosphate Control in Patients With CKD. Kidney Int Rep 2019; 4:1043-1056. [PMID: 31440695 PMCID: PMC6698320 DOI: 10.1016/j.ekir.2019.06.002] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/27/2019] [Accepted: 06/03/2019] [Indexed: 02/08/2023] Open
Abstract
Hyperphosphatemia is a common complication in patients with chronic kidney disease (CKD), particularly in those requiring renal replacement therapy. The importance of controlling serum phosphate has long been recognized based on observational epidemiological studies that linked increased phosphate levels to adverse outcomes and higher mortality risk. Experimental data further supported the role of phosphate in the development of bone and cardiovascular diseases. Recent advances in our understanding of the mechanisms involved in phosphate homeostasis have made it clear that the serum phosphate concentration depends on a complex interplay among the kidneys, intestinal tract, and bone, and is tightly regulated by a complex endocrine system. Moreover, the source of dietary phosphate and the use of phosphate-based additives in industrialized foods are additional factors that are of particular importance in CKD. Not surprisingly, the management of hyperphosphatemia is difficult, and, despite a multifaceted approach, it remains unsuccessful in many patients. An additional issue is the fact that the supposedly beneficial effect of phosphate lowering on hard clinical outcomes in interventional trials is a matter of ongoing debate. In this review, we discuss currently available treatment approaches for controlling hyperphosphatemia, including dietary phosphate restriction, reduction of intestinal phosphate absorption, phosphate removal by dialysis, and management of renal osteodystrophy, with particular focus on practical challenges and limitations, and on potential benefits and harms.
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Affiliation(s)
- Fellype Carvalho Barreto
- Service of Nephrology, Department of Internal Medicine, Federal University of Paraná, Curitiba, Paraná, Brazil
| | - Daniela Veit Barreto
- Service of Nephrology, Department of Internal Medicine, Federal University of Paraná, Curitiba, Paraná, Brazil
| | - Ziad A Massy
- Institut National de la Santé et de la Recherche Médicale U-1018, Team 5, Centre de Recherche en Epidémiologie et Santé des Populations, Versailles Saint-Quentin-en-Yvelines University (Paris-Ile-de-France-Ouest University), Paris-Sud University and Paris Saclay University, Villejuif, France.,Division of Nephrology, Ambroise Paré Hospital, Assistance Publique-Hôpitaux de Paris, Boulogne Billancourt/Paris, France
| | - Tilman B Drüeke
- Institut National de la Santé et de la Recherche Médicale U-1018, Team 5, Centre de Recherche en Epidémiologie et Santé des Populations, Versailles Saint-Quentin-en-Yvelines University (Paris-Ile-de-France-Ouest University), Paris-Sud University and Paris Saclay University, Villejuif, France
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32
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Ix JH, Isakova T, Larive B, Raphael KL, Raj DS, Cheung AK, Sprague SM, Fried LF, Gassman JJ, Middleton JP, Flessner MF, Block GA, Wolf M. Effects of Nicotinamide and Lanthanum Carbonate on Serum Phosphate and Fibroblast Growth Factor-23 in CKD: The COMBINE Trial. J Am Soc Nephrol 2019; 30:1096-1108. [PMID: 31085679 DOI: 10.1681/asn.2018101058] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 03/11/2019] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Higher serum phosphate and fibroblast growth factor-23 (FGF23) levels may be modifiable to prevent cardiovascular disease in CKD. Short-term studies have reported modest efficacy in phosphate and FGF23 reduction with intestinal phosphate binders in CKD. METHODS To investigate effects of lanthanum carbonate (LC; a phosphate binder) and/or nicotinamide (NAM; an inhibitor of active intestinal phosphate transport) on serum phosphate and FGF23 in stage 3b/4 CKD, we conducted a randomized trial among individuals with eGFR 20-45 ml/min per 1.73 m2 to NAM (750 mg twice daily) plus LC (1000 mg thrice daily), NAM plus LC placebo, LC plus NAM placebo, or double placebo for 12 months. Dual primary end points were change from baseline in serum phosphate and intact FGF23 concentrations. RESULTS Mean eGFR for the 205 participants was 32ml/min per 1.73 m2. At baseline, serum phosphate was 3.7 mg/dl and median FGF23 was 99 pg/ml (10th, 90th percentiles: 59, 205). Mean rates of change in phosphate increased slightly over 12 months in all groups and did not differ significantly across arms. Similarly, percent changes in FGF23 per 12 months increased for all arms except LC plus placebo, and did not differ significantly across arms. Gastrointestinal symptoms limited adherence. Adverse events rates were similar across arms. CONCLUSIONS LC and/or NAM treatment did not significantly lower serum phosphate or FGF23 in stage 3b/4 CKD over 12 months. Although these agents appeared safe, intestinal symptoms limited adherence. Reducing phosphate and FGF23 in nondialysis CKD will require new approaches.
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Affiliation(s)
- Joachim H Ix
- Division of Nephrology-Hypertension, Department of Medicine and .,Nephrology Section, Veterans Affairs San Diego Healthcare System, La Jolla, California.,Division of Preventive Medicine, Department of Family Medicine and Public Health, University of California San Diego, San Diego, California
| | - Tamara Isakova
- Division of Nephrology and Hypertension.,Department of Medicine, and.,Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Brett Larive
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Kalani L Raphael
- Salt Lake City Veterans Affairs Healthcare System and.,Division of Nephrology and Hypertension, University of Utah Health, Salt Lake City, Utah
| | - Dominic S Raj
- Division of Renal Diseases and Hypertension, George Washington University, Washington, DC
| | - Alfred K Cheung
- Salt Lake City Veterans Affairs Healthcare System and.,Division of Nephrology and Hypertension, University of Utah Health, Salt Lake City, Utah
| | - Stuart M Sprague
- Division of Nephrology, Department of Medicine, NorthShore University Health System-University of Chicago, Pritzker School of Medicine, Evanston, Illinois
| | - Linda F Fried
- Renal Section.,Veterans Affairs Pittsburgh Healthcare System, and.,University of Pittsburgh School of Medicine and University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Jennifer J Gassman
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - John P Middleton
- Division of Nephrology.,Department of Medicine, and.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Michael F Flessner
- Division of Kidney, Urologic, and Hematologic Disorders, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland; and
| | | | - Myles Wolf
- Division of Nephrology.,Department of Medicine, and.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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Khalid SA, Inayat F, Tahir MK, Younus A, Ahmad HI, Bokhari SRA, Yaqoob U. Nicotinic Acid as a Phosphate-lowering Agent in Patients with End-stage Renal Disease on Maintenance Hemodialysis: A Single-center Prospective Study. Cureus 2019; 11:e4566. [PMID: 31281749 PMCID: PMC6599467 DOI: 10.7759/cureus.4566] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Hyperphosphatemia increases the risk of mortality and morbidity in patients with end-stage renal disease (ESRD). In addition to dietary restriction and renal replacement therapy, phosphorus-binding agents are the mainstay of treatment. While the use of calcium-containing binders has certain limitations, non-calcium-based binders are expensive and not readily available in developing countries. Previous studies on nicotinic acid as a phosphorus-lowering agent have limited data. In this study, we evaluated the efficacy of nicotinic acid in patients with ESRD on hemodialysis (HD) in Pakistan. Methods Forty-five patients with ESRD on maintenance HD having serum phosphorus levels >5.5 mg/dL were recruited. Nicotinic acid 250 mg was administered with food for four weeks. All patients with serum phosphorus levels <8 mg/dL were placed on a twice-daily regimen while the rest received it three times a day with meals. Patients were assessed at the beginning and end of the study with serum phosphorus levels. Results Mean age of the sample population was 44.6 ± 13.9 years and 57.8% of participants were male. Serum phosphorus level before treatment ranged from 5.6 to 10.8 mg/dL (mean, 6.91 ± 1.33). After nicotinic acid therapy, it ranged from 2.60 to 8.70 mg/dL (mean, 5.82 ± 1.40). Mean decrease in serum phosphorus levels with nicotinic acid after one month of treatment was 1.08 ± 1.16 mg/dL (p-value <0.001). Conclusion Nicotinic acid is effective in lowering serum phosphorus levels in patients with ESRD who are under renal replacement therapy with maintenance HD.
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Affiliation(s)
- Syed A Khalid
- Nephrology, Allama Iqbal Medical College, Lahore, PAK
| | - Faisal Inayat
- Internal Medicine, Allama Iqbal Medical College, Lahore, PAK
| | | | - Aamna Younus
- Internal Medicine, Shifa College of Medicine, Islamabad, PAK
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Clement J, Wong M, Poljak A, Sachdev P, Braidy N. The Plasma NAD + Metabolome Is Dysregulated in "Normal" Aging. Rejuvenation Res 2018; 22:121-130. [PMID: 30124109 PMCID: PMC6482912 DOI: 10.1089/rej.2018.2077] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Nicotinamide adenine dinucleotide (NAD+) is an essential pyridine nucleotide that serves as an electron carrier in cellular metabolism and plays a crucial role in the maintenance of balanced redox homeostasis. Quantification of NAD+:NADH and NADP+:NADPH ratios are pivotal to a wide variety of cellular processes, including intracellular secondary messenger signaling by CD38 glycohydrolases, DNA repair by poly(adenosine diphosphate ribose) polymerase (PARP), epigenetic regulation of gene expression by NAD-dependent histone deacetylase enzymes known as sirtuins, and regulation of the oxidative pentose phosphate pathway. We quantified changes in the NAD+ metabolome in plasma samples collected from consenting healthy human subjects across a wide age range (20-87 years) using liquid chromatography coupled to tandem mass spectrometry. Our data show a significant decline in the plasma levels of NAD+, NADP+, and other important metabolites such as nicotinic acid adenine dinucleotide (NAAD) with age. However, an age-related increase in the reduced form of NAD+ and NADP+-NADH and NADPH-and nicotinamide (NAM), N-methyl-nicotinamide (MeNAM), and the products of adenosine diphosphoribosylation, including adenosine diphosphate ribose (ADPR) was also reported. Whereas, plasma levels of nicotinic acid (NA), nicotinamide mononucleotide (NMN), and nicotinic acid mononucleotide (NAMN) showed no statistically significant changes across age groups. Taken together, our data cumulatively suggest that age-related impairments are associated with corresponding alterations in the extracellular plasma NAD+ metabolome. Our future research will seek to elucidate the role of modulating NAD+ metabolites in the treatment and prevention of age-related diseases.
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Affiliation(s)
| | - Matthew Wong
- 2 Centre for Healthy Brain Ageing, University of New South Wales, School of Psychiatry, Sydney, Australia
| | - Anne Poljak
- 2 Centre for Healthy Brain Ageing, University of New South Wales, School of Psychiatry, Sydney, Australia.,3 Mark Wainwright Analytical Centre, University of New South Wales, Sydney, Australia.,4 School of Medical Sciences, University of New South Wales, Sydney, Australia
| | - Perminder Sachdev
- 2 Centre for Healthy Brain Ageing, University of New South Wales, School of Psychiatry, Sydney, Australia.,5 Neuropsychiatric Institute, Euroa Centre, Prince of Wales Hospital, Sydney, Australia
| | - Nady Braidy
- 2 Centre for Healthy Brain Ageing, University of New South Wales, School of Psychiatry, Sydney, Australia
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35
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Marks J. The role of SLC34A2 in intestinal phosphate absorption and phosphate homeostasis. Pflugers Arch 2018; 471:165-173. [PMID: 30343332 PMCID: PMC6325986 DOI: 10.1007/s00424-018-2221-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 10/08/2018] [Accepted: 10/10/2018] [Indexed: 12/13/2022]
Abstract
There has recently been significant interest in the concept of directly targeting intestinal phosphate transport to control hyperphosphatemia in patients with chronic kidney disease. However, we do not have a complete understanding of the cellular mechanisms that govern dietary phosphate absorption. Studies in the 1970s documented both active and passive pathways for intestinal phosphate absorption. However, following the cloning of the intestinal SLC34 cotransporter, NaPi-IIb, much of the research focused on the role of this protein in active transcellular phosphate absorption and the factors involved in its regulation. Generation of a conditional NaPi-IIb knockout mouse has demonstrated that this protein is critical for the maintenance of skeletal integrity during periods of phosphate restriction and that under normal physiological conditions, the passive sodium-independent pathway is likely be the more dominant pathway for intestinal phosphate absorption. The review aims to summarise the most recent developments in our understanding of the role of the intestine in phosphate homeostasis, including the acute and chronic renal adaptations that occur in response to dietary phosphate intake. Evidence regarding the overall contribution of the transcellular and paracellular pathways for phosphate absorption will be discussed, together with the clinical benefit of inhibiting these pathways for the treatment of hyperphosphatemia in chronic kidney disease.
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Affiliation(s)
- Joanne Marks
- Department of Neuroscience, Physiology and Pharmacology, Royal Free Campus, University College London, Rowland Hill Street, London, NW3 2PF, UK.
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36
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Wagener EDA, Souma N, Hodakowski A, Martinez C, Fox P, Mehta R, O'Brien MJ, Bolon M, Kulik L, Yang GY, Isakova T. A Patient With CKD Develops Cholestatic Liver Injury During a Clinical Trial. Kidney Int Rep 2018; 3:5-10. [PMID: 29340307 PMCID: PMC5762939 DOI: 10.1016/j.ekir.2017.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Emma D A Wagener
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Nao Souma
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Alexander Hodakowski
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Carlos Martinez
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Patrick Fox
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Rupal Mehta
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Matthew J O'Brien
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Maureen Bolon
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Laura Kulik
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Guang-Yu Yang
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Tamara Isakova
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Malhotra R, Katz R, Hoofnagle A, Bostom A, Rifkin DE, Mcbride R, Probstfield J, Block G, Ix JH. The Effect of Extended Release Niacin on Markers of Mineral Metabolism in CKD. Clin J Am Soc Nephrol 2018; 13:36-44. [PMID: 29208626 PMCID: PMC5753310 DOI: 10.2215/cjn.05440517] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 10/03/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND OBJECTIVES Niacin downregulates intestinal sodium-dependent phosphate transporter 2b expression and reduces intestinal phosphate transport. Short-term studies have suggested that niacin lowers serum phosphate concentrations in patients with CKD and ESRD. However, the long-term effects of niacin on serum phosphate and other mineral markers are unknown. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The Atherothrombosis Intervention in Metabolic Syndrome with Low HDL/High Triglycerides: Impact on Global Health Trial was a randomized, double-blind, placebo-controlled trial testing extended release niacin in persons with prevalent cardiovascular disease. We examined the effect of randomized treatment with niacin (1500 or 2000 mg) or placebo on temporal changes in markers of mineral metabolism in 352 participants with eGFR<60 ml/min per 1.73 m2 over 3 years. Changes in each marker were compared over time between the niacin and placebo arms using linear mixed effects models. RESULTS Randomization to niacin led to 0.08 mg/dl lower plasma phosphate concentrations per year of treatment compared with placebo (P<0.01) and 0.25 mg/dl lower mean phosphate 3 years after baseline (3.32 versus 3.57 mg/dl; P=0.03). In contrast, randomization to niacin was not associated with statistically significant changes in plasma intact fibroblast growth factor 23, parathyroid hormone, calcium, or vitamin D metabolites over 3 years. CONCLUSIONS The use of niacin over 3 years lowered serum phosphorous concentrations but did not affect other markers of mineral metabolism in participants with CKD.
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Affiliation(s)
- Rakesh Malhotra
- Division of Nephrology-Hypertension, Department of Medicine and
- Imperial Valley Family Care Medical Group, El Centro, California
| | - Ronit Katz
- Division of Nephrology, Department of Medicine
| | | | - Andrew Bostom
- Division of Hypertension and Kidney Diseases, Rhode Island Hospital, Providence, Rhode Island
| | - Dena E. Rifkin
- Division of Nephrology-Hypertension, Department of Medicine and
- Division of Preventive Medicine, Department of Family Medicine and Public Health, University of California, San Diego, California
- Nephrology Section, Veterans Affairs San Diego Healthcare System, San Diego, California
| | | | - Jeffrey Probstfield
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington
| | | | - Joachim H. Ix
- Division of Nephrology-Hypertension, Department of Medicine and
- Division of Preventive Medicine, Department of Family Medicine and Public Health, University of California, San Diego, California
- Nephrology Section, Veterans Affairs San Diego Healthcare System, San Diego, California
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Affiliation(s)
- Tilman B. Drüeke
- Institut National de la Santé et de la Recherche Médicale U-1018, Team 5, Centre de Recherche en Epidémiologie et Santé des Populations, Versailles Saint-Quentin-en-Yvelines University (Paris-Ile-de-France-Ouest University), Paris-Sud University and Paris Saclay University, Villejuif, France; and
| | - Ziad A. Massy
- Institut National de la Santé et de la Recherche Médicale U-1018, Team 5, Centre de Recherche en Epidémiologie et Santé des Populations, Versailles Saint-Quentin-en-Yvelines University (Paris-Ile-de-France-Ouest University), Paris-Sud University and Paris Saclay University, Villejuif, France; and
- Division of Nephrology, Ambroise Paré Hospital, Assistance Publique-Hôpitaux de Paris, Boulogne Billancourt/Paris, France
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Liabeuf S, Ryckelynck JP, El Esper N, Ureña P, Combe C, Dussol B, Fouque D, Vanhille P, Frimat L, Thervet E, Mentaverri R, Prié D, Choukroun G. Randomized Clinical Trial of Sevelamer Carbonate on Serum Klotho and Fibroblast Growth Factor 23 in CKD. Clin J Am Soc Nephrol 2017; 12:1930-1940. [PMID: 29074818 PMCID: PMC5718266 DOI: 10.2215/cjn.03030317] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 08/15/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Epidemiologic studies suggest that higher serum phosphaturic hormone fibroblast growth factor 23 levels are associated with increase morbidity and mortality. The aim of the FGF23 Reduction Efficacy of a New Phosphate Binder in CKD Trial was to evaluate the effect of sevelamer carbonate on serum C-terminal fibroblast growth factor 23 levels in normophosphatemic patients with CKD stage 3b/4. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Patients with CKD, eGFR between 45 and 15 ml/min per 1.73 m2, fasting serum phosphate concentration >3.1 mg/dl, and serum C-terminal fibroblast growth factor 23 >80 relative units/ml were included in our double-blind, placebo-controlled, randomized multicenter study. All patients received 100,000 IU cholecalciferol at time of randomization. Participants received either placebo or sevelamer carbonate 4.8 g daily during a 12-week period. Biologic parameters, including serum C-terminal fibroblast growth factor 23, intact fibroblast growth factor 23, and α-klotho, were evaluated at baseline and 12 weeks after inclusion. RESULTS Of 96 screened patients, 78 (mean±SD age: 63±13 years old; 70% men; mean eGFR: 27±9 ml/min per 1.73 m2) met the inclusion criteria. At baseline, mean eGFR was 27±9 ml/min per 1.73 m2, mean serum phosphate level was 3.8±0.5 mg/dl, and median (interquartile range) serum C-terminal fibroblast growth factor 23 level was 157 (120-241) relative units/ml. After 12 weeks of treatment, urinary phosphate-to-creatinine ratio fell significantly in the sevelamer group. The sevelamer and placebo groups did not differ significantly in terms of median change in serum C-terminal fibroblast growth factor 23 levels: the median (interquartile range) change was 38 (-13-114) relative units/ml in the placebo group and 37 (-1-101) relative units/ml in the sevelamer group (P=0.77). There was no significant difference in serum intact fibroblast growth factor 23, α-klotho, or phosphate levels changes between the two groups. Serum total and LDL cholesterol levels fell significantly in the sevelamer group. CONCLUSIONS In our double-blind, placebo-controlled, randomized study performed in normophosphatemic patients with CKD, a 12-week course of sevelamer carbonate significantly reduced phosphaturia without changing serum phosphorus but did not significantly modify serum C-terminal fibroblast growth factor 23 and intact fibroblast growth factor 23 or α-klotho levels.
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Affiliation(s)
- Sophie Liabeuf
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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Yamada S, Giachelli CM. Vascular calcification in CKD-MBD: Roles for phosphate, FGF23, and Klotho. Bone 2017; 100:87-93. [PMID: 27847254 PMCID: PMC5429216 DOI: 10.1016/j.bone.2016.11.012] [Citation(s) in RCA: 187] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 09/23/2016] [Accepted: 11/11/2016] [Indexed: 02/07/2023]
Abstract
Vascular calcification (VC) is highly prevalent in aging, diabetes mellitus, and chronic kidney disease (CKD). VC is a strong predictor of cardiovascular morbidity and mortality in the CKD population. Complex pathological mechanisms are involved in the development of VC, including osteochondrogenic differentiation and apoptosis of vascular smooth muscle cells, instability and release of extracellular vesicles loaded calcium and phosphate, and elastin degradation. Elevated serum phosphate is a late manifestation of CKD, and has been shown to accelerate mineral deposition in both the vessel wall and heart valves. α-Klotho and fibroblast growth factor 23 (FGF23) are emerging factors in CKD-mineral and bone disorder (CKD-MBD) and are thought to be involved in the pathogenesis of uremic VC. There are discordant reports regarding the biomedical effects of FGF23 on VC. In contrast, mounting evidence supports a well-supported protective role for α-Klotho on VC. Further studies are warranted to elucidate potential roles of FGF23 and α-Klotho in VC and to determine where and how they are synthesized in normal and disease conditions. A thorough systemic evaluation of the biomedical interplay of phosphate, FGF23, and α-Klotho may potentially lead to new therapeutic options for patients with CKD-MBD.
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Affiliation(s)
- Shunsuke Yamada
- Department of Bioengineering, University of Washington, Seattle, WA 98195, USA
| | - Cecilia M Giachelli
- Department of Bioengineering, University of Washington, Seattle, WA 98195, USA.
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