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Vigil FMB, Vaz de Castro PAS, Hasparyk UG, Bartolomei VS, Simões E Silva AC. Potential Role of Bone Metabolism Markers in Kidney Transplant Recipients. Curr Med Chem 2024; 31:2809-2820. [PMID: 38332694 DOI: 10.2174/0109298673250291231121052433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 07/17/2023] [Accepted: 10/27/2023] [Indexed: 02/10/2024]
Abstract
BACKGROUND The impact of treatments, suppressing the immune system, persistent hyperparathyroidism, and other risk factors on mineral and bone disorder (MBD) after kidney transplantation is well-known. However, there is limited knowledge about their effect on bone metabolism biomarkers. This study aimed to investigate the influence of kidney transplant on these markers, comparing them to patients undergoing hemodialysis and healthy individuals. METHODS In this cross-sectional study, three groups were included: kidney transplant patients (n = 57), hemodialysis patients (n = 26), and healthy controls (n = 31). Plasma concentrations of various bone metabolism biomarkers, including Dickkopf-related protein 1, osteoprotegerin, osteocalcin, osteopontin, sclerostin, and fibroblast growth factor 23, were measured. Associations between these biomarkers and clinical and laboratory data were evaluated. RESULTS A total of 114 patients participated. Transplant recipients had significantly lower levels of Dickkopf-related protein 1, osteoprotegerin, osteocalcin, osteopontin, sclerostin, and fibroblast growth factor 23 compared to hemodialysis patients. Alkaline phosphatase levels positively correlated with osteopontin (r = 0.572, p < 0.001), while fibroblast growth factor 23 negatively correlated with 25-hydroxyvitamin D (r = -0.531, p = 0.019). The panel of bone biomarkers successfully predicted hypercalcemia (area under the curve [AUC] = 0.852, 95% confidence interval [CI] = 0.679-1.000) and dyslipidemia (AUC = 0.811, 95% CI 0.640-0.982) in transplant recipients. CONCLUSION Kidney transplantation significantly improves mineral and bone disorders associated with end-stage kidney disease by modulating MBD markers and reducing bone metabolism markers, such as Dickkopf-related protein 1, osteoprotegerin, osteocalcin, osteopontin, and sclerostin. Moreover, the panel of bone biomarkers effectively predicted hypercalcemia and dyslipidemia in transplant recipients.
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Affiliation(s)
- Flávia Maria Borges Vigil
- Interdisciplinary Laboratory of Medical Investigation, Unit of Pediatric Nephrology, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
- Hospital Evangélico, Belo Horizonte, MG, Brazil
| | - Pedro Alves Soares Vaz de Castro
- Interdisciplinary Laboratory of Medical Investigation, Unit of Pediatric Nephrology, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Ursula Gramiscelli Hasparyk
- Interdisciplinary Laboratory of Medical Investigation, Unit of Pediatric Nephrology, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Victória Soares Bartolomei
- Interdisciplinary Laboratory of Medical Investigation, Unit of Pediatric Nephrology, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Ana Cristina Simões E Silva
- Interdisciplinary Laboratory of Medical Investigation, Unit of Pediatric Nephrology, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
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2
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Ramirez-Sandoval JC, Marino L, Cojuc-Konigsberg G, Reul-Linares E, Pichardo-Cabrera ND, Cruz C, Hernández-Paredes EN, Berman-Parks N, Vidal-Ruíz V, Estrada-Linares JM, Reza-Albarrán AA, Correa-Rotter R, Morales-Buenrostro LE. Long-term effects of hypercalcemia in kidney transplant recipients with persistent hyperparathyroidism. J Nephrol 2023:10.1007/s40620-023-01815-5. [PMID: 38032457 DOI: 10.1007/s40620-023-01815-5] [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: 06/04/2023] [Accepted: 10/19/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Hypercalcemia is highly prevalent in kidney transplant recipients with hyperparathyroidism. However, its long-term impact on graft function is uncertain. METHODS We conducted a prospective cohort study investigating adverse graft outcomes associated with persistent hypercalcemia (free calcium > 5.2 mg/dL in ≥ 80% of measures) and inappropriately elevated intact parathyroid hormone (> 30 pg/mL) in kidney transplant recipients. Asymptomatic mild hypercalcemia was monitored unless complications developed. RESULTS We included 385 kidney transplant recipients. During a 4-year (range 1-9) median follow-up time, 62% of kidney transplant recipients presented persistent hypercalcemia. Compared to kidney transplant recipients without hypercalcemia, there were no significant differences in graft dysfunction (10% vs. 12%, p = 0.61), symptomatic urolithiasis (5% vs. 3%, p = 0.43), biopsy-proven calcium deposits (6% vs. 5%, p = 1.0), fractures (6% vs. 4%, p = 0.64), and a composite outcome of urolithiasis, calcium deposits, fractures, and parathyroidectomy indication (16% vs. 13%, p = 0.55). In a subset of 76 kidney transplant recipients, subjects with persistent hypercalcemia had higher urinary calcium (median 84 [43-170] vs. 38 [24-64] mg/day, p = 0.03) and intact fibroblast growth factor 23 (median 36 [24-54] vs. 27 [19-40] pg/mL, p = 0.04), and lower 25-hydroxyvitamin D levels (11.3 ± 1.2 vs. 16.3 ± 1.4 ng/mL, p < 0.001). In multivariate analysis, pretransplant intact parathyroid hormone < 300 pg/mL was associated with a reduced risk of post-transplant hypercalcemia (OR 0.51, 95% CI 0.32-0.80). CONCLUSIONS Long-term persistent mild hypercalcemia (tertiary hyperparathyroidism) was frequent in kidney transplant recipients in our series. This condition presented with lower phosphate and 25-hydroxyvitamin D, and higher urinary calcium and intact fibroblast growth factor 23 levels compared to kidney transplant recipients without hypercalcemia, resembling a mild form of primary hyperparathyroidism. Despite these metabolic derangements, the risk of adverse graft outcomes was low.
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Affiliation(s)
- Juan Carlos Ramirez-Sandoval
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, colonia Sección XVI, 14080, Mexico City, CDMX, Mexico.
| | - Lluvia Marino
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, colonia Sección XVI, 14080, Mexico City, CDMX, Mexico
| | - Gabriel Cojuc-Konigsberg
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, colonia Sección XVI, 14080, Mexico City, CDMX, Mexico
| | - Estefania Reul-Linares
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, colonia Sección XVI, 14080, Mexico City, CDMX, Mexico
| | - Nathalie Desire Pichardo-Cabrera
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, colonia Sección XVI, 14080, Mexico City, CDMX, Mexico
| | - Cristino Cruz
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, colonia Sección XVI, 14080, Mexico City, CDMX, Mexico
| | - Elisa Naomi Hernández-Paredes
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, colonia Sección XVI, 14080, Mexico City, CDMX, Mexico
| | - Nathan Berman-Parks
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, colonia Sección XVI, 14080, Mexico City, CDMX, Mexico
| | - Vanessa Vidal-Ruíz
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, colonia Sección XVI, 14080, Mexico City, CDMX, Mexico
| | - Jonathan Mauricio Estrada-Linares
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, colonia Sección XVI, 14080, Mexico City, CDMX, Mexico
| | - Alfredo Adolfo Reza-Albarrán
- Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ricardo Correa-Rotter
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, colonia Sección XVI, 14080, Mexico City, CDMX, Mexico
| | - Luis Eduardo Morales-Buenrostro
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, colonia Sección XVI, 14080, Mexico City, CDMX, Mexico
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3
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Okada M, Sato T, Hasegawa Y, Futamura K, Hiramitsu T, Ichimori T, Goto N, Narumi S, Takeda A, Watarai Y. Persistent hyperparathyroidism after preemptive kidney transplantation. Clin Exp Nephrol 2023; 27:882-889. [PMID: 37351681 PMCID: PMC10504143 DOI: 10.1007/s10157-023-02371-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 06/11/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Long-term dialysis vintage is a predictor of persistent hyperparathyroidism (HPT) after kidney transplantation (KTx). Recently, preemptive kidney transplantation (PKT) has increased. However, the incidence, predictors, and clinical implications of HPT after PKT are unclear. Here, we aimed to elucidate these considerations. METHODS In this retrospective cohort study, we enrolled patients who underwent PKT between 2000 and 2016. Those who lost their graft within 1 year posttransplant were excluded. HPT was defined as an intact parathyroid hormone (PTH) level exceeding 80 pg/mL or hypercalcemia unexplained by causes other than HPT. Patients were divided into two groups based on the presence of HPT 1 year after PKT. The primary outcome was the predictors of HPT after PKT, and the secondary outcome was graft survival. RESULTS Among the 340 consecutive patients who underwent PKT, 188 did not have HPT (HPT-free group) and 152 had HPT (HPT group). Multivariate logistic regression analysis revealed that pretransplant PTH level (P < 0.001; odds ratio [OR], 5.480; 95% confidence interval [CI], 2.070-14.50) and preoperative donor-estimated glomerular filtration rate (P = 0.033; OR, 0.978; 95% CI, 0.957-0.998) were independent predictors of HPT after PKT. Death-censored graft survival was significantly lower in the HPT group than that in the HPT-free group (90.4% vs. 96.4% at 10 years, P = 0.009). CONCLUSIONS Pretransplant PTH levels and donor kidney function were independent predictors of HPT after PKT. In addition, HPT was associated with worse graft outcomes even after PKT.
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Affiliation(s)
- Manabu Okada
- Department of Transplant Surgery and Transplant Nephrology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, 4668650, Japan.
| | - Tetsuhiko Sato
- Department of Diabetes and Endocrinology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Showa-ku, Nagoya, Aichi, Japan
| | - Yuki Hasegawa
- Department of Transplant Surgery and Transplant Nephrology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, 4668650, Japan
| | - Kenta Futamura
- Department of Transplant Surgery and Transplant Nephrology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, 4668650, Japan
| | - Takahisa Hiramitsu
- Department of Transplant Surgery and Transplant Nephrology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, 4668650, Japan
| | - Toshihiro Ichimori
- Department of Transplant Surgery and Transplant Nephrology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, 4668650, Japan
| | - Norihiko Goto
- Department of Transplant Surgery and Transplant Nephrology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, 4668650, Japan
| | - Shunji Narumi
- Department of Transplant Surgery and Transplant Nephrology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, 4668650, Japan
| | - Asami Takeda
- Department of Nephrology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Showa-ku, Nagoya, Aichi, Japan
| | - Yoshihiko Watarai
- Department of Transplant Surgery and Transplant Nephrology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, 4668650, Japan
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4
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Ganesan C, Holmes M, Liu S, Montez-Rath M, Conti S, Chang TC, Lenihan CR, Cheng XS, Chertow GM, Leppert JT, Pao AC. Kidney Stone Events after Kidney Transplant in the United States. Clin J Am Soc Nephrol 2023; 18:777-784. [PMID: 37071657 PMCID: PMC10278781 DOI: 10.2215/cjn.0000000000000176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 04/05/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Kidney stone disease is common and can lead to complications such as AKI, urinary tract obstruction, and urosepsis. In kidney transplant recipients, complications from kidney stone events can also lead to rejection and allograft failure. There is limited information on the incidence of kidney stone events in transplant recipients. METHODS We identified 83,535 patients from the United States Renal Data System who received their first kidney transplant between January 1, 2007, and December 31, 2018. We examined the incidence of kidney stone events and identified risk factors associated with a kidney stone event in the first 3 years after transplantation. RESULTS We found 1436 patients (1.7%) who were diagnosed with a kidney stone in the 3 years after kidney transplant. The unadjusted incidence rate for a kidney stone event was 7.8 per 1000 person-years. The median time from transplant to a kidney stone diagnosis was 0.61 (25%-75% range 0.19-1.46) years. Patients with a history of kidney stones were at greatest risk of a kidney stone event after transplant (hazard ratio [HR], 4.65; 95% confidence interval [CI], 3.82 to 5.65). Other notable risk factors included a diagnosis of gout (HR, 1.53; 95% CI, 1.31 to 1.80), hypertension (HR, 1.29; 95% CI, 1.00 to 1.66), and a dialysis of vintage of ≥9 years (HR, 1.48; 95% CI, 1.18 to 1.86; ref vintage ≤2.5 years). CONCLUSIONS Approximately 2% of kidney transplant recipients were diagnosed with a kidney stone in the 3 years after kidney transplant. Risk factors of a kidney stone event include a history of kidney stones and longer dialysis vintage.
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Affiliation(s)
- Calyani Ganesan
- Division of Nephrology, Department of Medicine, Stanford University, Stanford, California
| | - Malorie Holmes
- Division of Nephrology, Department of Medicine, Stanford University, Stanford, California
| | - Sai Liu
- Division of Nephrology, Department of Medicine, Stanford University, Stanford, California
| | - Maria Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University, Stanford, California
| | - Simon Conti
- Department of Urology, Stanford University, Stanford, California
| | - Timothy C. Chang
- Department of Urology, Stanford University, Stanford, California
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Colin R. Lenihan
- Division of Nephrology, Department of Medicine, Stanford University, Stanford, California
| | - Xingxing S. Cheng
- Division of Nephrology, Department of Medicine, Stanford University, Stanford, California
| | - Glenn M. Chertow
- Division of Nephrology, Department of Medicine, Stanford University, Stanford, California
| | - John T. Leppert
- Division of Nephrology, Department of Medicine, Stanford University, Stanford, California
- Department of Urology, Stanford University, Stanford, California
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Alan C. Pao
- Division of Nephrology, Department of Medicine, Stanford University, Stanford, California
- Department of Urology, Stanford University, Stanford, California
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California
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5
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Okada M, Tominaga Y, Sato T, Tomosugi T, Futamura K, Hiramitsu T, Ichimori T, Goto N, Narumi S, Kobayashi T, Uchida K, Watarai Y. Elevated parathyroid hormone one year after kidney transplantation is an independent risk factor for graft loss even without hypercalcemia. BMC Nephrol 2022; 23:212. [PMID: 35710357 PMCID: PMC9205154 DOI: 10.1186/s12882-022-02840-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 06/06/2022] [Indexed: 12/02/2022] Open
Abstract
Background Hypercalcemic hyperparathyroidism has been associated with poor outcomes after kidney transplantation (KTx). However, the clinical implications of normocalcemic hyperparathyroidism after KTx are unclear. This retrospective cohort study attempted to identify these implications. Methods Normocalcemic recipients who underwent KTx between 2000 and 2016 without a history of parathyroidectomy were included in the study. Those who lost their graft within 1 year posttransplant were excluded. Normocalcemia was defined as total serum calcium levels of 8.5–10.5 mg/dL, while hyperparathyroidism was defined as when intact parathyroid hormone levels exceeded 80 pg/mL. The patients were divided into two groups based on the presence of hyperparathyroidism 1 year after KTx. The primary outcome was the risk of graft loss. Results Among the 892 consecutive patients, 493 did not have hyperparathyroidism (HPT-free group), and 399 had normocalcemic hyperparathyroidism (NC-HPT group). Ninety-five patients lost their grafts. Death-censored graft survival after KTx was significantly lower in the NC-HPT group than in the HPT-free group (96.7% vs. 99.6% after 5 years, respectively, P < 0.001). Cox hazard analysis revealed that normocalcemic hyperparathyroidism was an independent risk factor for graft loss (P = 0.002; hazard ratio, 1.94; 95% confidence interval, 1.27–2.98). Conclusions Normocalcemic hyperparathyroidism 1 year after KTx was an independent risk factor for death-censored graft loss. Early intervention of elevated parathyroid hormone levels may lead to better graft outcomes, even without overt hypercalcemia. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02840-5.
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Affiliation(s)
- Manabu Okada
- Department of Transplant and Endocrine Surgery, Japanese Red Cross Nagoya Daini Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, 4668650, Japan.
| | - Yoshihiro Tominaga
- Department of Transplant and Endocrine Surgery, Japanese Red Cross Nagoya Daini Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, 4668650, Japan
| | - Tetsuhiko Sato
- Department of Diabetes and Endocrinology, Japanese Red Cross Nagoya Daini Hospital, Showa-ku, Nagoya, Aichi, Japan
| | - Toshihide Tomosugi
- Department of Transplant and Endocrine Surgery, Japanese Red Cross Nagoya Daini Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, 4668650, Japan
| | - Kenta Futamura
- Department of Transplant and Endocrine Surgery, Japanese Red Cross Nagoya Daini Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, 4668650, Japan
| | - Takahisa Hiramitsu
- Department of Transplant and Endocrine Surgery, Japanese Red Cross Nagoya Daini Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, 4668650, Japan
| | - Toshihiro Ichimori
- Department of Transplant and Endocrine Surgery, Japanese Red Cross Nagoya Daini Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, 4668650, Japan
| | - Norihiko Goto
- Department of Transplant and Endocrine Surgery, Japanese Red Cross Nagoya Daini Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, 4668650, Japan
| | - Shunji Narumi
- Department of Transplant and Endocrine Surgery, Japanese Red Cross Nagoya Daini Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, 4668650, Japan
| | - Takaaki Kobayashi
- Department of Renal Transplant Surgery, Aichi Medical University School of Medicine, Nagakute, Aichi, Japan
| | - Kazuharu Uchida
- Department of Renal Transplant Surgery, Masuko Memorial Hospital, Nakamura-ku, Nagoya, Aichi, Japan
| | - Yoshihiko Watarai
- Department of Transplant and Endocrine Surgery, Japanese Red Cross Nagoya Daini Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, Aichi, 4668650, Japan
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6
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Hasparyk UG, Vigil FMB, Bartolomei VS, Nunes VM, Simões e Silva AC. Chronic Kidney Disease-Mineral Bone Disease biomarkers in kidney transplant patients. Curr Med Chem 2022; 29:5230-5253. [DOI: 10.2174/0929867329666220318105856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 01/16/2022] [Accepted: 01/20/2022] [Indexed: 11/22/2022]
Abstract
Background:
Chronic Kidney Disease associated with Mineral Bone Disease (CKD-MBD) is frequent in kidney transplant patients. Post-transplantation bone disease is complex, especially in patients with pre-existing metabolic bone disorders that are further affected by immunosuppressive medications and changes in renal allograft function. Main biochemical abnormalities of mineral metabolism in kidney transplantation (KTx) include hypophosphatemia, hyperparathyroidism (HPTH), insufficiency or deficiency of vitamin D, and hypercalcemia.
Objective:
This review aimed to summarize the pathophysiology and main biomarkers of CKD-MBD in KTx.
Methods:
A comprehensive and non-systematic search in PubMed was independently made with an emphasis on biomarkers in mineral bone disease in KTx.
Results:
CKD-MBD can be associated with numerous factors including secondary HPTH, metabolic dysregulations before KTx, and glucocorticoids therapy in post-transplant subjects. Fibroblast growth factor 23 (FGF23) reaches normal levels after KTx with good allograft function, while calcium, vitamin D and phosphorus, ultimately, result in hypercalcemia, persistent vitamin D insufficiency, and hypophosphatemia respectively. As for PTH levels, there is an initial tendency of a significant decrease, followed by a raise due to secondary or tertiary HPTH. In regard to sclerostin levels, there is no consensus in the literature.
Conclusion:
KTx patients should be continuously evaluated for mineral homeostasis and bone status, both cases with successful kidney transplantation and those with reduced functionality. Additional research on CKD-MBD pathophysiology, diagnosis, and management is essential to guarantee long-term graft function, better prognosis, good quality of life, and reduced mortality for KTx patients.
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Affiliation(s)
- Ursula Gramiscelli Hasparyk
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Flávia Maria Borges Vigil
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Victória Soares Bartolomei
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Vitor Moreira Nunes
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Ana Cristina Simões e Silva
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
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7
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Molinari P, Alfieri CM, Mattinzoli D, Campise M, Cervesato A, Malvica S, Favi E, Messa P, Castellano G. Bone and Mineral Disorder in Renal Transplant Patients: Overview of Pathology, Clinical, and Therapeutic Aspects. Front Med (Lausanne) 2022; 9:821884. [PMID: 35360722 PMCID: PMC8960161 DOI: 10.3389/fmed.2022.821884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/08/2022] [Indexed: 12/25/2022] Open
Abstract
Renal transplantation (RTx) allows us to obtain the resolution of the uremic status but is not frequently able to solve all the metabolic complications present during end-stage renal disease. Mineral and bone disorders (MBDs) are frequent since the early stages of chronic kidney disease (CKD) and strongly influence the morbidity and mortality of patients with CKD. Some mineral metabolism (MM) alterations can persist in patients with RTx (RTx-p), as well as in the presence of complete renal function recovery. In those patients, anomalies of calcium, phosphorus, parathormone, fibroblast growth factor 23, and vitamin D such as bone and vessels are frequent and related to both pre-RTx and post-RTx specific factors. Many treatments are present for the management of post-RTx MBD. Despite that, the guidelines that can give clear directives in MBD treatment of RTx-p are still missed. For the future, to obtain an ever-greater individualisation of therapy, an increase of the evidence, the specificity of international guidelines, and more uniform management of these anomalies worldwide should be expected. In this review, the major factors related to post-renal transplant MBD (post-RTx-MBD), the main mineral metabolism biochemical anomalies, and the principal treatment for post-RTx MBD will be reported.
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Affiliation(s)
- Paolo Molinari
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Policlinico, Milan, Italy
| | - Carlo Maria Alfieri
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- *Correspondence: Carlo Maria Alfieri ;
| | - Deborah Mattinzoli
- Renal Research Laboratory Fondazione IRCCS Ca' Granda Ospedale Policlinico, Milan, Italy
| | - Mariarosaria Campise
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Policlinico, Milan, Italy
| | - Angela Cervesato
- Department of Nephrology, Clinical and Translational Sciences, Università degli Studi della Campania L.Vanvitelli, Naples, Italy
| | - Silvia Malvica
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Policlinico, Milan, Italy
| | - Evaldo Favi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Department of General Surgery, Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Piergiorgio Messa
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giuseppe Castellano
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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8
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Abstract
After kidney transplantation, mineral and bone disorders are associated with higher risk of fractures and consequent morbidity and mortality. Disorders of calcium and phosphorus, vitamin D deficiency, and hyperparathyroidism are also common. The epidemiology of bone disease has evolved over the past several decades due to changes in immunosuppressive regimens, mainly glucocorticoid minimization or avoidance. The assessment of bone disease in kidney transplant recipients relies on risk factor recognition and bone mineral density assessment. Several drugs have been trialed for the treatment of post-transplant mineral and bone disorders. This review will focus on the epidemiology, effect, and treatment of metabolic and skeletal derangements in the transplant recipient.
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Affiliation(s)
- Pascale Khairallah
- Section of Nephrology and Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, Texas
| | - Thomas L. Nickolas
- Division of Nephrology, Columbia University Irving Medical Center, New York, New York
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9
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Alfieri C, Mattinzoli D, Messa P. Tertiary and Postrenal Transplantation Hyperparathyroidism. Endocrinol Metab Clin North Am 2021; 50:649-662. [PMID: 34774239 DOI: 10.1016/j.ecl.2021.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Patients who have undergone kidney transplantation (KTx) (KTxps) are a distinctive population characterized by the persistence of some metabolic anomalies present during end-stage renal disease. Mineral metabolism (MM) parameters are frequently altered after KTx. These alterations involve calcium, phosphorus, vitamin D, and parathormone (PTH) disarrangements. At present, there is little consensus about the correct monitoring and management of PTH disorders in KTxps. This article presents the prevalence and epidemiologic and clinical impact of post-KTx hyper-PTH. The principal biochemical and instrumental investigations and the therapeutic options for these conditions are also reported.
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Affiliation(s)
- Carlo Alfieri
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Policlinico, Via Commenda 15, Milan 20122, Italy; Department of Clinical Sciences and Community Health, University of Milan, Via Festa del Perdono, 7, Milan 20122, Italy
| | - Deborah Mattinzoli
- Renal Research Laboratory Fondazione IRCCS Ca' Granda Ospedale Policlinico, Via Pace 9, Milan 20122, Italy
| | - Piergiorgio Messa
- Department of Nephrology, Dialysis and Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Policlinico, Via Commenda 15, Milan 20122, Italy; Department of Clinical Sciences and Community Health, University of Milan, Via Festa del Perdono, 7, Milan 20122, Italy.
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10
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Rivelli GG, Lima MLD, Mazzali M. Therapy for persistent hypercalcemic hyperparathyroidism post-renal transplant: cinacalcet versus parathyroidectomy. ACTA ACUST UNITED AC 2021; 42:315-322. [PMID: 32720971 PMCID: PMC7657049 DOI: 10.1590/2175-8239-jbn-2019-0207] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 05/04/2020] [Indexed: 01/14/2023]
Abstract
Background: Persistent hyperparathyroidism post-transplant is associated with increases in the incidence of cardiovascular events, fractures, and deaths. The aim of this study was to compare both therapeutic options available: parathyroidectomy (PTX) and the calcimimetic agent cinacalcet. Methods: A single center retrospective study including adult renal transplant recipients who developed hypercalcemia due to persistent hyperparathyroidism. Inclusion criteria: PTH > 65 pg/mL with serum calcium > 11.5 mg/dL at any time after transplant or serum calcium persistently higher than 10.2 mg/dL one year after transplant. Patients treated with cinacalcet (n=46) were compared to patients treated with parathyroidectomy (n=30). Follow-up period was one year. Clinical and laboratory data were analyzed to compare efficacy and safety of both therapeutic modalities. Results: PTX controlled calcemia faster (month 1 x month 6) and reached significantly lower levels at month 12 (9.1±1.2 vs 9.7±0.8 mg/dL, p < 0.05); PTX patients showed significantly higher levels of serum phosphate (3.8±1.0 vs 2.9±0.5 mg/dL, p < 0.05) and returned PTH to normal levels (45±51 pg/mL). Cinacalcet, despite controlling calcium and phosphate in the long term, decreased but did not correct PTH (197±97 pg/mL). The proportion of patients that remained with PTH above normal range was 95% in the cinacalcet group and 22% in the PTX group. Patients treated with cinacalcet had better renal function (creatinine 1.2±0.3 vs 1.7±0.7 mg/dL, p < 0.05). Conclusions: Surgical treatment was superior to cinacalcet to correct the metabolic disorders of hyperparathyroidism despite being associated with worse renal function in the long term. Cinacalcet proved to be a safe and well tolerated drug.
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Affiliation(s)
- Gabriel Giollo Rivelli
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Departamento de Clínica Médica, Campinas, SP, Brasil.,Universidade Estadual de Campinas, Laboratório de Investigação em Transplante, Campinas, SP, Brasil
| | - Marcelo Lopes de Lima
- Universidade Estadual de Campinas, Laboratório de Investigação em Transplante, Campinas, SP, Brasil.,Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Departamento de Cirurgia, Campinas, SP, Brasil
| | - Marilda Mazzali
- Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Departamento de Clínica Médica, Campinas, SP, Brasil.,Universidade Estadual de Campinas, Laboratório de Investigação em Transplante, Campinas, SP, Brasil
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11
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Tantisattamo E, Ho BT, Workeneh BT. Editorial: Metabolic Changes After Kidney Transplantation. Front Med (Lausanne) 2021; 8:709644. [PMID: 34307432 PMCID: PMC8297834 DOI: 10.3389/fmed.2021.709644] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 05/31/2021] [Indexed: 01/21/2023] Open
Affiliation(s)
- Ekamol Tantisattamo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, University of California, Irvine School of Medicine, Orange, CA, United States.,Nephrology Section, Department of Medicine, Tibor Rubin Veterans Affairs Medical Center, Veterans Affairs Long Beach Healthcare System, Long Beach, CA, United States.,Multi-Organ Transplant Center, Section of Nephrology, Department of Internal Medicine, William Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, MI, United States
| | - Bing T Ho
- Comprehensive Transplant Center, Division of Nephrology and Hypertension, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Biruh T Workeneh
- Section of Nephrology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
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12
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van der Plas WY, Gomes Neto AW, Berger SP, Pol RA, Kruijff S, Bakker SJL, de Borst MH. Association of time-updated plasma calcium and phosphate with graft and patient outcomes after kidney transplantation. Am J Transplant 2021; 21:2437-2447. [PMID: 33331113 PMCID: PMC8359271 DOI: 10.1111/ajt.16457] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 11/08/2020] [Accepted: 12/09/2020] [Indexed: 01/25/2023]
Abstract
Disturbances in calcium-phosphate homeostasis are common after kidney transplantation. We aimed to assess the relationship between deregulations in plasma calcium and phosphate over time and mortality and death-censored graft failure (DCGF). In this prospective cohort study, we included kidney transplant recipients with ≥2 plasma calcium and phosphate measurements. Data were analyzed using time-updated Cox regression analyses adjusted for potential confounders including time-updated kidney function. We included 2769 patients (mean age 47 ± 14 years, 42.3% female) with 138 496 plasma calcium and phosphate levels (median [IQR] 43 [31-61] measurements per patient). During follow-up of 16.3 [8.7-25.2] years, 17.2% developed DCGF and 7.9% died. Posttransplant hypercalcemia was associated with an increased risk of mortality (1.63 [1.31-2.00], p < 0.0001), but not with DCGF. Hyperphosphatemia was associated with both DCGF (2.59 [2.05-3.27], p < .0001) and mortality (3.14 [2.58-3.82], p < .0001). Only the association between hypercalcemia and mortality remained significant in sensitivity analyses censored by a simultaneous eGFR <45 mL/min/1.73 m2 . Hypocalcemia and hypophosphatemia were not consistently associated with either outcome. Posttransplant hypercalcemia, even in the presence of preserved kidney function, was associated with an increased mortality risk. Associations of hyperphosphatemia with DCGF and mortality may be driven by eGFR.
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Affiliation(s)
- Willemijn Y. van der Plas
- Department of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - António W. Gomes Neto
- Department of Internal Medicine Division of NephrologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Stefan P. Berger
- Department of Internal Medicine Division of NephrologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Robert A. Pol
- Department of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Schelto Kruijff
- Department of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Stephan J. L. Bakker
- Department of Internal Medicine Division of NephrologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands,TransplantLines Biobank and Cohort StudyGroningenThe Netherlands
| | - Martin H. de Borst
- Department of Internal Medicine Division of NephrologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
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13
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Frey S, Goronflot T, Kerleau C, Gourraud PA, Caillard C, Hourmant M, Mirallié É, Figueres L. Parathyroidectomy or cinacalcet: Do we still not know the best option for graft function in kidney-transplanted patients? A meta-analysis. Surgery 2021; 170:727-735. [PMID: 33810851 DOI: 10.1016/j.surg.2021.02.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 01/15/2021] [Accepted: 02/17/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Tertiary hyperparathyroidism occurs in 25% to 50% of kidney-transplanted patients. Indication of parathyroidectomy is now discussed, since the calcimimetic agent, cinacalcet, is an alternate option. The effects of either of these treatments on graft function remain controversial, studied only in small cohorts showing either decrease or absence of modification. We performed a meta-analysis to evaluate the evolution of graft function after surgical or medical treatment. METHODS Studies assessing graft function in tertiary hyperparathyroidism after parathyroidectomy or cinacalcet introduction were enrolled into quantitative analysis using Pubmed, Embase, and Cochrane databases following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis reporting guidelines. Among 68 screened studies, 18 had no missing data and were included for statistical analyses. We performed random effect meta-analysis to determine changes in serum creatinine and estimated glomerular filtration rate. RESULTS Seven studies assessing the evolution of graft function 6 and/or 12 months after parathyroidectomy and 13 after administration of cinacalcet were included. Meta-analysis found no significant variations after parathyroidectomy in serum creatinine (6 studies, 314 patients) and estimated glomerular filtration rate (2 studies, 105 patients). No significant variation was found after administration of cinacalcet in serum creatinine (10 studies, 404 patients) and estimated glomerular filtration rate (6 studies, 149 patients). A significant heterogeneity between the studies (P < .01, Cochran's Q) was found. CONCLUSION Meta-analysis shows that parathyroidectomy and cinacalcet do not significantly impair graft function in patients with tertiary hyperparathyroidism. However, the significant heterogeneity between selected studies, partially explained by the lack of consensual definition of tertiary hyperparathyroidism, limits the conclusions of all previously published series.
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Affiliation(s)
- Samuel Frey
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des maladies de l'Appareil Digestif, Hôtel Dieu, CHU Nantes, France; Université de Nantes, France
| | - Thomas Goronflot
- CHU de Nantes, INSERM, CIC 1413, Pôle Hospitalo-Universitaire 11: Santé Publique, Santé au Travail, Pharmacie, Stérilisation, Clinique des Données, France
| | - Clarisse Kerleau
- Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, France
| | - Pierre-Antoine Gourraud
- Université de Nantes, France; CHU de Nantes, INSERM, CIC 1413, Pôle Hospitalo-Universitaire 11: Santé Publique, Santé au Travail, Pharmacie, Stérilisation, Clinique des Données, France
| | - Cécile Caillard
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des maladies de l'Appareil Digestif, Hôtel Dieu, CHU Nantes, France
| | - Maryvonne Hourmant
- Université de Nantes, France; Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, France; Service de néphrologie-immunologie clinique, CHU de Nantes, France
| | - Éric Mirallié
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des maladies de l'Appareil Digestif, Hôtel Dieu, CHU Nantes, France; Université de Nantes, France
| | - Lucile Figueres
- Université de Nantes, France; Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, France; Service de néphrologie-immunologie clinique, CHU de Nantes, France.
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14
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Okada M, Hiramitsu T, Ichimori T, Goto N, Narumi S, Watarai Y, Sato T, Tominaga Y. Comparison of Pre- and Post-transplant Parathyroidectomy in Renal Transplant Recipients and the Impact of Parathyroidectomy Timing on Calcium Metabolism and Renal Allograft Function: A Retrospective Single-Center Analysis. World J Surg 2020; 44:498-507. [PMID: 31399797 DOI: 10.1007/s00268-019-05124-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The effect of parathyroidectomy (PTx) timing on serum calcium (Ca) levels and renal functions in renal transplant recipients with severe hyperparathyroidism (HPT) remains unclear. We retrospectively aimed to investigate and compare the clinical data of patients who underwent pre- and post-transplant PTx and elucidated the impact of PTx timing on serum Ca levels and renal graft outcomes after renal transplantation (RTx). METHODS During January 2000-December 2016, 53 and 55 patients underwent post-transplant PTx (Post-RTx group) and pretransplant PTx (Pre-RTx group), respectively. The serum Ca levels and estimated glomerular filtration rate (eGFR) were assessed in both groups. RESULTS At the end of the follow-up, the serum Ca levels were significantly higher and the incidence of hypocalcemia was significantly lower in the Pre-RTx group than in the Post-RTx group [9.5 vs. 8.9 mg/dL, P < 0.001; 14.5% vs. 34.0%, P = 0.024]. The decrease in the eGFR 12-36 months after RTx was more significant in the Post-RTx group than in the Pre-RTx group (-13.8% vs. -0.9%; P = 0.001). A logistic regression involving age, sex, dialysis period, and serum parathormone level revealed that post-transplant PTx is an independent risk factor for persistent hypocalcemia at the end of the follow-up (P = 0.034) and for a >20% decrease in the eGFR 12-36 months after RTx (P = 0.029). CONCLUSIONS In renal transplant candidates with severe HPT, pretransplant PTx should be considered to prevent persistent hypocalcemia and deterioration of the renal graft function.
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Affiliation(s)
- Manabu Okada
- Department of Transplantation and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, 4668650, Japan.
| | - Takahisa Hiramitsu
- Department of Transplantation and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, 4668650, Japan
| | - Toshihiro Ichimori
- Department of Transplantation and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, 4668650, Japan
| | - Norihiko Goto
- Department of Transplantation and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, 4668650, Japan
| | - Shunji Narumi
- Department of Transplantation and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, 4668650, Japan
| | - Yoshihiko Watarai
- Department of Transplantation and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, 4668650, Japan
| | - Tetsuhiko Sato
- Department of General Internal Medicine, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Yoshihiro Tominaga
- Department of Transplantation and Endocrine Surgery, Nagoya Daini Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya, 4668650, Japan
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15
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Evenepoel P, Claes K, Meijers B, Laurent MR, Bammens B, Naesens M, Sprangers B, Cavalier E, Kuypers D. Natural history of mineral metabolism, bone turnover and bone mineral density in de novo renal transplant recipients treated with a steroid minimization immunosuppressive protocol. Nephrol Dial Transplant 2020; 35:697-705. [PMID: 30339234 DOI: 10.1093/ndt/gfy306] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 08/15/2018] [Indexed: 01/08/2023] Open
Abstract
The skeletal effects of renal transplantation are not completely understood, especially in patients managed with a steroid minimization immunosuppressive protocol and long term. We enrolled 69 adult transplant recipients (39 males; ages 51.1 ± 12.2 years), free of antiresorptive therapy and managed with a steroid minimization immunosuppressive protocol, into a 5-year prospective observational study to evaluate changes in areal bone mineral density (aBMD), mineral metabolism and bone remodelling. Dual energy X-ray absorptiometry, laboratory parameters of mineral metabolism (including parathyroid hormone, sclerostin and fibroblast growth factor 23) and non-renal cleared bone turnover markers (BTMs) (bone-specific alkaline phosphatase, trimeric N-terminal propeptide and tartrate-resistant acid phosphatase 5b) were assessed at baseline and 1 and 5 years post-transplantation. The mean cumulative methylprednisolone exposure at 1 and 5 years amounted to 2.5 ± 0.8 and 5.8 ± 3.3 g, respectively. Overall, bone remodelling activity decreased after transplantation. Post-transplant aBMD changes were minimal and were significant only in the ultradistal radius during the first post-operative year {median -2.2% [interquartile range (IQR) -5.9-1.2] decline, P = 0.01} and in the lumbar spine between Years 1 and 5 [median 1.6% (IQR -3.2-7.0) increase, P = 0.009]. BTMs, as opposed to mineral metabolism parameters and cumulative corticosteroid exposure, associated with aBMD changes, both in the early and late post-transplant period. Most notably, aBMD changes inversely associated with bone remodelling changes. In summary, in de novo renal transplant recipients treated with a steroid minimization immunosuppressive protocol, BMD changes are limited, highly variable and related to remodelling activity rather than corticosteroid exposure.
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Affiliation(s)
- Pieter Evenepoel
- Laboratory of Nephrology, KU Leuven Department of Microbiology and Immunology, University Hospitals Leuven, Leuven, Belgium.,Department of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Kathleen Claes
- Laboratory of Nephrology, KU Leuven Department of Microbiology and Immunology, University Hospitals Leuven, Leuven, Belgium.,Department of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Björn Meijers
- Laboratory of Nephrology, KU Leuven Department of Microbiology and Immunology, University Hospitals Leuven, Leuven, Belgium.,Department of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | | | - Bert Bammens
- Laboratory of Nephrology, KU Leuven Department of Microbiology and Immunology, University Hospitals Leuven, Leuven, Belgium.,Department of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Maarten Naesens
- Laboratory of Nephrology, KU Leuven Department of Microbiology and Immunology, University Hospitals Leuven, Leuven, Belgium.,Department of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Ben Sprangers
- Laboratory of Nephrology, KU Leuven Department of Microbiology and Immunology, University Hospitals Leuven, Leuven, Belgium.,Department of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | | | - Dirk Kuypers
- Laboratory of Nephrology, KU Leuven Department of Microbiology and Immunology, University Hospitals Leuven, Leuven, Belgium.,Department of Nephrology, University Hospitals Leuven, Leuven, Belgium
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16
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Parathyroidectomy for tertiary hyperparathyroidism after second kidney transplantation: a case report. CEN Case Rep 2020; 10:208-213. [PMID: 33079356 DOI: 10.1007/s13730-020-00545-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 10/04/2020] [Indexed: 10/23/2022] Open
Abstract
Successful kidney transplantation usually resolves secondary hyperparathyroidism (SHPT). However, some patients fail to normalize, and their condition is often referred to as tertiary hyperparathyroidism (THPT). Surgical consensus on the timing of post-transplant parathyroidectomy (PTX) for THPT has not been reached. Herein, we report a case of a 58-year-old post-transplant woman, considering the concrete timing of PTX for both SHPT and THPT. She initiated hemodialysis with end-stage renal disease at the age of 24, and underwent first kidney transplantation at the age of 28. When peritoneal dialysis (PD) was induced due to the worsening kidney function at the age of 50, the serum intact parathyroid hormone (iPTH) level remarkably increased (2332 pg/mL). Although cinacalcet was administered, the patient's iPTH levels were not sufficiently suppressed for seven years. Diagnostic images including ultrasound, computed tomography, and 99mTc-methoxyisobutylisonitrile scintigraphy indicated THPT as the reason for prolonged post-transplant hypercalcemia. Therefore, PTX was performed 14 months after the second transplantation. Histology showed nodular hyperplasia of all parathyroid glands, indicating autonomous secretion of parathyroid hormone. In general, patients with more severe THPT are recognized with more severe SHPT prior to transplantation during the dialysis period. We should consider a referral for surgery based on the individual risk factors. We recommend to perform parathyroidectomy earlier, before the kidney transplantation in the clinical suspicion of severe SHPT.
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17
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Lu YP, Zeng S, Chu C, Hasan AA, Slowinski T, Yin LH, Krämer BK, Hocher B. Non-oxidized PTH (n-oxPTH) is associated with graft loss in kidney transplant recipients. Clin Chim Acta 2020; 508:92-97. [DOI: 10.1016/j.cca.2020.05.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/11/2020] [Accepted: 05/11/2020] [Indexed: 11/30/2022]
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18
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Chevarria J, Sexton DJ, Murray SL, Adeel CE, O'Kelly P, Williams YE, O'Seaghdha CM, Little DM, Conlon PJ. Calcium and phosphate levels after kidney transplantation and long-term patient and allograft survival. Clin Kidney J 2020; 14:1106-1113. [PMID: 33841855 PMCID: PMC8023198 DOI: 10.1093/ckj/sfaa061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 03/25/2020] [Indexed: 11/28/2022] Open
Abstract
Background Non-traditional cardiovascular risk factors, including calcium and phosphate derangement, may play a role in mortality in renal transplant. The data regarding this effect are conflicting. Our aim was to assess the impact of calcium and phosphate derangements in the first 90 days post-transplant on allograft and recipient outcomes. Methods We performed a retrospective cohort review of all-adult, first renal transplants in the Republic of Ireland between 1999 and 2015. We divided patients into tertiles based on serum phosphate and calcium levels post-transplant. We assessed their effect on death-censored graft survival and all-cause mortality. We used Stata for statistical analysis and did survival analysis and spline curves to assess the association. Results We included 1525 renal transplant recipients. Of the total, 86.3% had hypophosphataemia and 36.1% hypercalcaemia. Patients in the lowest phosphate tertile were younger, more likely female, had lower weight, more time on dialysis, received a kidney from a younger donor, had less delayed graft function and better transplant function compared with other tertiles. Patients in the highest calcium tertile were younger, more likely male, had higher body mass index, more time on dialysis and better transplant function. Adjusting for differences between groups, we were unable to show any difference in death-censored graft failure [phosphate = 1.14, 95% confidence interval (CI) 0.92–1.41; calcium = 0.98, 95% CI 0.80–1.20] or all-cause mortality (phosphate = 1.10, 95% CI 0.91–1.32; calcium = 0.96, 95% CI 0.81–1.13) based on tertiles of calcium or phosphate in the initial 90 days. Conclusions Hypophosphataemia and hypercalcaemia are common occurrences post-kidney transplant. We have identified different risk factors for these metabolic derangements. The calcium and phosphate levels exhibit no independent association with death-censored graft failure and mortality.
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Affiliation(s)
- Julio Chevarria
- Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Donal J Sexton
- Department of Nephrology, Trinity College Dublin, Dublin, Ireland
| | - Susan L Murray
- Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Chaudhry E Adeel
- Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Patrick O'Kelly
- Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Yvonne E Williams
- Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Conall M O'Seaghdha
- Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland
| | - Dilly M Little
- Department of Urology and Transplant, Beaumont Hospital, Dublin, Ireland
| | - Peter J Conlon
- Department of Nephrology and Transplantation, Beaumont Hospital, Dublin, Ireland.,Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
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19
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Pekar JD, Grzych G, Durand G, Haas J, Lionet A, Brousseau T, Glowacki F, Maboudou P. Calcium state estimation by total calcium: the evidence to end the never-ending story. Clin Chem Lab Med 2020; 58:222-231. [PMID: 31473684 DOI: 10.1515/cclm-2019-0568] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 08/07/2019] [Indexed: 01/31/2023]
Abstract
Background Total blood calcium (TCa) is routinely used to diagnose and manage mineral and bone metabolism disorders. Numerous laboratories adjust TCa by albumin, though literature suggests there are some limits to this approach. Here we report a large retrospective study on agreement rate between ionized calcium (iCa) measurement and TCa or albumin-adjusted calcium measurements. Methods We retrospectively selected 5055 samples with simultaneous measurements of iCa, TCa, albumin and pH. We subgrouped our patients according to their estimated glomerular filtration rate (eGFR), albumin levels and pH. We analyzed each patient's calcium state with iCa as reference to determine agreement rate with TCa and albumin-adjusted calcium using Payne, Clase, Jain and Ridefelt formulas. Results The Payne formula performed poorly in patients with abnormal albumin, eGFR or pH levels. In patients with low albumin levels or blood pH disorders, Payne-adjusted calcium may overestimate the calcium state in up to 80% of cases. Similarly, TCa has better agreement with iCa in the case of hypoalbuminemia, but performed similarly to the Payne formula in patients with physiological albumin levels. The global agreement rate for Clase, Jain and Ridefelt formulas suggests significant improvement compared to Payne calcium adjustment but no significant improvement compared to TCa. Conclusions Total and albumin-adjusted calcium measurement leads to a misclassification of calcium status. Moreover, accurate calcium state determination depends on blood pH levels, whose measurement requires the same pre-analytical restrictions as iCa measurement. We propose that iCa should instead become the reference method to determine the real calcium state.
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Affiliation(s)
| | - Guillaume Grzych
- Centre de Biologie Pathologie, Laboratoire d'Hormonologie, Métabolisme-Nutrition, Oncologie, rue du Pr J. Leclercq, CHU Lille, F-59000 Lille, France.,Université de Lille, INSERM UMR-1011, Lille, France
| | - Gatien Durand
- CHU Lille, UF 8832 Biochimie automatisée, Lille, France
| | - Joël Haas
- Université de Lille, INSERM UMR-1011, Lille, France
| | - Arnaud Lionet
- CHU Lille, Service de Néphrologie et Transplantation, Lille, France
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20
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Abstract
Significant advances in immunosuppressive therapies have been made in renal transplantation, leading to increased allograft and patient survival. Despite improvement in overall patient survival, patients continue to require management of persistent post-transplant hyperparathyroidism. Medications that treat persistent hyperparathyroidism include vitamin D, vitamin D analogues, and calcimimetics. Medication side effects such as hypocalcemia or hypercalcemia, and adynamic bone disease, may lead to a decrease in the drugs. When medical management fails to control persistent post-transplant hyperparathyroidism, treatment is a parathyroidectomy. Surgical techniques are not uniform between centers and surgeons. Undergoing the surgery may include a subtotal technique or a technique including total parathyroid gland resection with partial heterotopic gland reimplantation. In addition, there are possible post-surgical complications. The ideal treatment for persistent post-transplant hyperparathyroidism is the treatment and prevention of the condition while patients are being managed for their late-stage chronic kidney disease and end-stage renal disease.
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Affiliation(s)
- Rowena Delos Santos
- Division of Nephrology, Washington University in St. Louis, 660 S. Euclid Ave, Campus Box 8126, St. Louis, MO, 63110, USA.
| | - Ana Rossi
- Division of Nephrology and Transplantation, Maine Medical Center, Maine Transplant Program, 19 West St., Portland, ME, 04102, USA
| | - Daniel Coyne
- Division of Nephrology, Washington University in St. Louis, 660 S. Euclid Ave, Campus Box 8126, St. Louis, MO, 63110, USA
| | - Thin Thin Maw
- Division of Nephrology and Hypertension, Keck School of Medicine of USC, 2020 Zonal Ave, IRD 806, Los Angeles, CA, 90033, USA
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21
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Bone biomarkers in de novo renal transplant recipients. Clin Chim Acta 2019; 501:179-185. [PMID: 31734147 DOI: 10.1016/j.cca.2019.10.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 10/24/2019] [Indexed: 12/30/2022]
Abstract
Successful kidney transplantation (partly) corrects the physiologic and metabolic abnormalities driving chronic kidney disease - mineral and bone disorders. At the same time, renal transplant recipients are exposed to immunosuppressive agents that may affect bone metabolism. Bone biomarkers have been suggested as surrogates of or adjuncts to bone biopsy and imaging techniques to assess bone health and to classify risk of bone loss and fractures. Bone biomarkers may be classified as circulating factors that affect bone metabolism (commonly referred to as bone metabolism markers) or that reflect bone cell number and/or activity (commonly referred to as bone turnover markers). A growing body of evidence shows that successful renal transplantation has a major impact on both bone metabolism and bone turnover. Analytical issues, including the cross-reactivity with fragments, complicate the interpretation of bone biomarkers, especially in the setting of a rapid changing kidney function, as is the case after successful renal transplantation. Overall, bone turnover seems to decline following renal transplantation, but inter-individual variability is substantial. Preliminary evidence indicates that bone biomarkers may be useful in guiding mineral and bone therapy in renal transplant recipients.
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22
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Coche S, Cornet G, Morelle J, Labriola L, Kanaan N, Demoulin N. Hypercalcemia associated with Pneumocystis jirovecii pneumonia in renal transplant recipients: case report and literature review. Acta Clin Belg 2019; 76:75-78. [PMID: 31470765 DOI: 10.1080/17843286.2019.1655233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Pneumocystis jirovecii associated pneumonia is a potentially life-threatening opportunistic infection, occurring most frequently in the first year after renal transplantation, and may be associated with hypercalcemia. Clinical presentation:We report the case of a renal transplant recipient presenting with Pneumocystis jirovecii associated pneumonia and hypercalcemia due to ectopic production of 1,25-dihydroxyvitamin D, 6 years after renal transplantation. Calcemia and 1-25 hydroxyvitamin D levels normalized after our patient was treated by trimethoprim-sulfamethoxazole. Discussion: We review similar cases to delineate the clinical and biological profile of patients with Pneumocystis jirovecii pneumonia associated hypercalcemia. Conclusion:Physicians should evoke this diagnosis in renal transplant recipients presenting with pulmonary infection associated with hypercalcemia.
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Affiliation(s)
- Sophie Coche
- Division of Nephrology, Cliniques universitaires Saint-Luc , Brussels, Belgium
| | - Georges Cornet
- Division of Nephrology, Centre Hospitalier Peltzer-La Tourelle , Verviers, Belgium
| | - Johann Morelle
- Division of Nephrology, Cliniques universitaires Saint-Luc , Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain , Brussels, Belgium
| | - Laura Labriola
- Division of Nephrology, Cliniques universitaires Saint-Luc , Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain , Brussels, Belgium
| | - Nada Kanaan
- Division of Nephrology, Cliniques universitaires Saint-Luc , Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain , Brussels, Belgium
| | - Nathalie Demoulin
- Division of Nephrology, Cliniques universitaires Saint-Luc , Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain , Brussels, Belgium
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23
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Alagoz S, Trabulus S. Long-Term Evaluation of Mineral Metabolism After Kidney Transplantation. Transplant Proc 2019; 51:2330-2333. [PMID: 31402243 DOI: 10.1016/j.transproceed.2019.01.181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 01/28/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Persistence of abnormalities in mineral metabolism is common after kidney transplantation and appears to have a negative effect on survival. We aimed to evaluate the mineral metabolism and identify risk factors for persistent hyperparathyroidism (HPT) over 10 years. METHODS We retrospectively analyzed the medical records of 176 consecutive renal transplant patients. Serum creatinine, calcium, phosphorus, and intact parathyroid hormone (iPTH) levels before and after transplantation up to the 10th year post transplantation were recorded for 11 different dates. Calcium > 10.2 mg/dL was considered hypercalcemia, phosphorus < 2.5 mg/dL was considered hypophosphatemia, and iPTH > 2.5 times the upper limit was considered HPT. RESULTS After a major fall in the first 3 months, iPTH steadily decreased over 5 years. Thereafter, it stabilized at a level of 1.5 times the upper limit. Rates of persistent HPT were 9.2% and 10.7% in the fifth and 10th years, respectively. The rate of hypercalcemia increased up to 21.7% at the ninth month, and after 10 years, it was 5.9%. The rate of hypophosphatemia peaked at 33.3% in the first month, and it was 8.9% in 10th year. Multivariate analysis revealed that calcium (P = .047) and phosphorus (P = .041) at the time of transplantation and female sex (P = .037) were independent predictors of persistent HPT in the first year. iPTH correlated significantly with kidney function and pre-transplant iPTH. CONCLUSIONS High serum levels of iPTH, calcium, and phosphorus at the time of transplantation were risk factors for persistent HPT in kidney transplant recipients, especially when renal function was suboptimal.
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Affiliation(s)
- Selma Alagoz
- Division of Nephrology, Department of Internal Medicine, University of Health Sciences, Bagcilar Training and Research Hospital, Istanbul, Turkey.
| | - Sinan Trabulus
- Division of Nephrology, Department of Internal Medicine, Istanbul University Cerrahpasa, Cerrahpasa Medical Faculty, Istanbul, Turkey
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24
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Jo HA, Han KH, So YK, Jun H, Han SY. Effect of Cinacalcet in Kidney Transplant Patients With Hyperparathyroidism. Transplant Proc 2019; 51:1397-1401. [PMID: 31155177 DOI: 10.1016/j.transproceed.2019.01.141] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 01/28/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE In dialysis patients, cinacalcet could be an effective alternative to parathyroidectomy for treating hyperparathyroidism. In the present study, we aimed to determine the characteristics of subjects with persistent hyperparathyroidism who require parathyroidectomy despite the use of cinacalcet. METHODS Nine kidney transplant patients (7 men, 2 women; mean age 53.2 [SD, 8.9] years) who had tertiary hyperparathyroidism were reviewed in a single center. Pre- and postcinacalcet levels of calcium, phosphorous, intact parathyroid hormone (iPTH), and renal function were analyzed to evaluate the effect of cinacalcet treatment in these patients. The baseline parameters before cinacalcet treatment were compared in patients who did and did not undergo parathyroidectomy. RESULTS Cinacalcet reduced serum calcium levels in all patients (11.48 [SD, 0.73] mg/dL to 10.20 [0.70] mg/dL; P = .008). Serum phosphorous levels significantly increased from 2.28 (SD, 0.77) mg/dL to 3.02 (SD, 0.65) mg/dL (P = .03). The iPTH levels in 7 patients decreased, while the mean level remained unchanged in total subjects. The iPTH levels increased even with cinacalcet treatment in 2 patients. In 3 patients, serum calcium levels abruptly increased after cinacalcet withdrawal. Five patients who showed persistent hypercalcemia due to hyperparathyroidism underwent parathyroidectomy. These 5 patients had significantly different characteristics compared with 4 patients who did not undergo parathyroidectomy: hypercalcemia (11.92 [SD, 0.68] mg/dL vs 10.93 [SD, 0.26] mg/dL; P = .02), hypophosphatemia (1.74 [SD, 0.36] mg/dL vs 2.95 [SD, 0.58] mg/dL; P = .03), and hyperparathyroidism (252.2 [SD, 131.4] pg/dL vs 101.5 [SD, 18.4] pg/dL; P = .02). CONCLUSION Cinacalcet reduced hypercalcemia due to hyperparathyroidism in the transplant patients. However, patients who had pre-existing higher iPTH, hypercalcemia, and hypophosphatemia needed parathyroidectomy. Therefore, cinacalcet could be considered an alternative to parathyroidectomy in selected patients.
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Affiliation(s)
- Hyung Ah Jo
- Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, South Korea
| | - Kum Hyun Han
- Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, South Korea
| | - Yoon Kyoung So
- Department of Otolaryngology-Head and Neck Surgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, South Korea
| | - Heungman Jun
- Department of Surgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, South Korea
| | - Sang Youb Han
- Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, South Korea.
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25
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Pochineni V, Rondon-Berrios H. Electrolyte and Acid-Base Disorders in the Renal Transplant Recipient. Front Med (Lausanne) 2018; 5:261. [PMID: 30333977 PMCID: PMC6176109 DOI: 10.3389/fmed.2018.00261] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 08/29/2018] [Indexed: 12/17/2022] Open
Abstract
Kidney transplantation is the current treatment of choice for patients with end-stage renal disease. Innovations in transplantation and immunosuppression regimens have greatly improved the renal allograft survival. Based on recently published data from the Scientific Registry of Transplant recipients, prevalence of kidney transplants is steadily rising in the United States. Over 210,000 kidney transplant recipients were alive with a functioning graft in mid-2016, which is nearly twice as many as in 2005. While successful renal transplantation corrects most of the electrolyte and mineral abnormalities seen in advanced renal failure, the abnormalities seen in the post-transplant period are surprisingly different from those seen in chronic kidney disease. Multiple factors contribute to the high prevalence of these abnormalities that include level of allograft function, use of immunosuppressive medications and metabolic changes in the post-transplant period. Electrolyte disturbances are common in patients after renal transplantation, and several studies have tried to determine the clinical significance of these disturbances. In this manuscript we review the key aspects of the most commonly found post-transplant electrolyte abnormalities. We focus on their epidemiology, pathophysiology, clinical manifestations, and available treatment approaches.
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Affiliation(s)
- Vaishnavi Pochineni
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
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26
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Demir E, Karaoglan C, Yegen G, Sair B, Yazici H, Turkmen A, Sever MS. Extreme hypercalcemia in a kidney transplant recipient. CEN Case Rep 2018; 7:229-233. [PMID: 29705974 DOI: 10.1007/s13730-018-0334-1] [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: 12/26/2017] [Accepted: 04/21/2018] [Indexed: 10/17/2022] Open
Abstract
Post-transplant hypercalcemia is a major problem in renal transplant recipients, which may negatively affect both graft and patient survival. In this paper, we present a 66-year-old male kidney transplant recipient, who was admitted to our clinic with symptoms of fever, nausea, vomiting and lethargy. Laboratory data showed good renal function; however, a serum calcium level of 22.1 mg/dL. The patient was treated by isotonic saline together with furosemide and methylprednisolone. Because of treatment resistance, subcutaneous calcitonin and ibandronate were added to the treatment protocol as well. Since all these medications were not effective, hemodialysis with low-calcium (1.25 mmol/L) dialysate was applied for three consecutive days, which resulted in normalization of serum calcium. Several investigations were carried out for diagnosing the underlying etiology. Positron-emission tomography (PET)/CT revealed a strong diffuse uptake of FDG in the bones and spleen. A bone marrow biopsy showed diffuse interstitial infiltration of CD20 + neoplastic B cells and, thus, post transplant lymphoproliferative disease (PTLD) was diagnosed. Tacrolimus was switched to everolimus, mycophenolate mofetil was stopped, while treatment with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) was initiated. Despite all therapeutic interventions, the patient died of septic shock in the intensive care unit on the 10th day of emergency service admission. Importance of hemodialysis as an emergent treatment modality in extreme hypercalcemia, and unfavorable course of PTLD were underlined.
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Affiliation(s)
- Erol Demir
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.
| | - Cagla Karaoglan
- Department of Pathology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Gulcin Yegen
- Department of Pathology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Betul Sair
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Halil Yazici
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Aydin Turkmen
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Mehmet Sukru Sever
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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27
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Laucyte-Cibulskiene A, Boreikaite E, Aucina G, Gudynaite M, Rudminiene I, Anisko S, Vareikiene L, Gumbys L, Valanciene D, Ryliskyte L, Strupas K, Rimsevicius L, Miglinas M. Usefulness of pretransplant aortic arch calcification evaluation for kidney transplant outcome prediction in one year follow-up. Ren Fail 2018; 40:201-208. [PMID: 29619867 PMCID: PMC6014335 DOI: 10.1080/0886022x.2018.1455588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Vascular calcification (VC) is linked to post-transplant cardiovascular events and hypercalcemia which may influence kidney graft function in the long term. We aimed to evaluate whether pretransplant aortic arch calcification (AoAC) can predict post-transplant cardiovascular or cerebrovascular events (CVEs), and to assess its association with post-transplant plasma calcium levels and renal function in one-year follow-up. Our single-center observational prospective study enrolled 37 kidney transplant recipients (KTR) without previous history of vascular events. Two radiologists evaluated pretransplant AoAC on chest X-ray as suggested by Ogawa et al. in 2009. Cohen’s kappa coefficient was 0.71. The mismatching results were repeatedly reviewed and resulted in consensus. Carotid-femoral (cfPWV) and carotid-radial pulse wave velocity (crPWV) was measured using applanation tonometry before and one year after transplantation. Patient clinical, biochemical data, and cardiovascular/CVE rate were monitored within 1 year. We found out that eGFR1year correlated with eGFRdischarge and calcium based on hospital discharge data (β = 0.563, p = .004 and β = 51.360, p = .026, respectively). Multivariate linear regression revealed that donor age, donor gender, and recipient eGFRdischarge (R-squared 0.65, p = .002) better predict eGFR1year than AoAC combined with recipient eGFRdischarge (R-squared 0.35, p = .006). During 1-year follow-up, four (10.81%) patients experienced cardiovascular events, which were predicted by PWV ratio (HR 7.549, p = .045), but not related to AoAC score (HR 1.044, p = .158). In conclusion, KTR without previous vascular events have quite low cardiovascular/CVE rate within 1-year follow-up. VC evaluated as AoAC on pretransplant chest X-ray together with recipient eGFRdischarge could be related to kidney function in one-year follow-up.
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Affiliation(s)
- Agne Laucyte-Cibulskiene
- a Clinic of Gastroneterology, Nephrourology and Abdominal Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University , Vilnius , Lithuania
| | | | - Gediminas Aucina
- b Faculty of Medicine , Vilnius University , Vilnius , Lithuania
| | - Migle Gudynaite
- c Centre of Nephrology, Vilnius University Hospital Santaros Clinics , Vilnius , Lithuania
| | - Ilona Rudminiene
- c Centre of Nephrology, Vilnius University Hospital Santaros Clinics , Vilnius , Lithuania
| | - Sigita Anisko
- c Centre of Nephrology, Vilnius University Hospital Santaros Clinics , Vilnius , Lithuania
| | - Loreta Vareikiene
- c Centre of Nephrology, Vilnius University Hospital Santaros Clinics , Vilnius , Lithuania
| | - Liutauras Gumbys
- d Centre of Radiology and Nuclear Medicine , Vilnius University Hospital Santaros Clinics , Vilnius , Lithuania
| | - Dileta Valanciene
- b Faculty of Medicine , Vilnius University , Vilnius , Lithuania.,d Centre of Radiology and Nuclear Medicine , Vilnius University Hospital Santaros Clinics , Vilnius , Lithuania
| | - Ligita Ryliskyte
- b Faculty of Medicine , Vilnius University , Vilnius , Lithuania
| | - Kestutis Strupas
- a Clinic of Gastroneterology, Nephrourology and Abdominal Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University , Vilnius , Lithuania
| | - Laurynas Rimsevicius
- a Clinic of Gastroneterology, Nephrourology and Abdominal Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University , Vilnius , Lithuania
| | - Marius Miglinas
- a Clinic of Gastroneterology, Nephrourology and Abdominal Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University , Vilnius , Lithuania
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28
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Littbarski SA, Kaltenborn A, Gwiasda J, Beneke J, Arelin V, Schwager Y, Stupak JV, Marcheel IL, Emmanouilidis N, Jäger MD, Scheumann GFW, Klempnauer J, Schrem H. Timing of parathyroidectomy in kidney transplant candidates with secondary hyperparathryroidism: effect of pretransplant versus early or late post-transplant parathyroidectomy. Surgery 2017; 163:373-380. [PMID: 29284591 DOI: 10.1016/j.surg.2017.10.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Revised: 08/28/2017] [Accepted: 10/11/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND The timing of parathyroidectomy in kidney transplant candidates suffering from secondary hyperparathyroidism before versus early or late after transplantation remains controversial. METHODS The short-term follow-up cohort comprised 66 patients with 1-year post-transplant follow-up, while the long-term follow-up cohort contained 123 patients. Risk-adjusted identification of independent risk factors for compromised renal graft function (KDIGO stage ≥ IV) was performed using multivariable regression analysis adjusted for propensity score logits for parathyroidectomy before versus after renal transplantation. Intra-individual matched-pairs analyses were used to identify significant effects of post-transplant parathyroidectomy on graft function as assessed by estimated glomerular filtration rate (eGFR) and paired t tests. RESULTS Donor kidney function KDIGO stage III (P = .030; OR = 5.191, 95% CI: 1.100-24.508), donor blood group 0 (P = .005; OR = 0.176, 95% CI: 0.048-0.642), and post-transplant parathyroidectomy (P = .032; OR = 17.849, 95% CI: 1.086-293.268) were revealed as independent significant risk factors for compromised renal graft function in the short-term follow-up cohort using propensity score risk adjustment while post-transplant parathyroidectomy had no independent influence in the long-term follow-up cohort (P = .651). Parathyroidectomy after renal transplantation compromised graft function early after parathyroidectomy and at last follow-up in all post-transplant parathyroidectomy cases (P ≤ .004). Parathyroidectomy within the first post-transplant year was associated with compromised renal graft function until last follow-up (P = .004), while parathyroidectomy late post-transplant was not. CONCLUSION Parathyroidectomy should be conducted before transplantation or, if this is not possible, preferably after the first post-transplant year.
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Affiliation(s)
- Simon A Littbarski
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Alexander Kaltenborn
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Jill Gwiasda
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Jan Beneke
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Viktor Arelin
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany; Department of Nephrology, Hannover Medical School, Hannover, Germany
| | - Ysabell Schwager
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Julia V Stupak
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Indra L Marcheel
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Nikos Emmanouilidis
- General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Mark D Jäger
- General, Visceral and Minimally Invasive Surgery, Municipal Hospital Wolfenbüttel, Hannover, Germany
| | | | - Jürgen Klempnauer
- General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Harald Schrem
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Facility Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany; General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany.
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29
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Sarno G, Nappi R, Altieri B, Tirabassi G, Muscogiuri E, Salvio G, Paschou SA, Ferrara A, Russo E, Vicedomini D, Vincenzo C, Vryonidou A, Della Casa S, Balercia G, Orio F, De Rosa P. Current evidence on vitamin D deficiency and kidney transplant: What's new? Rev Endocr Metab Disord 2017; 18:323-334. [PMID: 28281103 DOI: 10.1007/s11154-017-9418-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Kidney transplant is the treatment of choice for end-stage chronic kidney disease. Kidneys generate 1,25-dihydroxyvitamin D (calcitriol) from 25-hydroxyvitamin D (calcidiol) for circulation in the blood to regulate calcium levels. Transplant patients with low calcidiol levels have an increased risk of metabolic and endocrine problems, cardiovascular disease, type 2 diabetes mellitus, poor graft survival, bone disorders, cancer, and mortality rate. The recommended calcidiol level after transplant is at least 30 ng/mL (75 nmol/L), which could require 1000-3000 IU/d vitamin D3 to achieve. Vitamin D3 supplementation studies have found improved endothelial function and acute rejection episodes. However, since kidney function may still be impaired, raising calcidiol levels may not lead to normal calcitriol levels. Thus, supplementation with calcitriol or an analog, alfacalcidiol, is often employed. Some beneficial effects found include possible improved bone health and reduced risk of chronic allograft nephropathy and cancer.
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Affiliation(s)
- Gerardo Sarno
- General Surgery and Transplantation Unit - "San Giovanni di Dio e Ruggi D'Aragona" University Hospital, Scuola Medica Salernitana, 84131, Salerno, Italy.
| | - Riccardo Nappi
- General Surgery and Transplantation Unit - "San Giovanni di Dio e Ruggi D'Aragona" University Hospital, Scuola Medica Salernitana, 84131, Salerno, Italy
- Nephrology and Dialisys Unit - "Santa Maria della Misericordia" Hospital, ASUIUD - Udine, Udine, Italy
| | - Barbara Altieri
- Institute of Medical Pathology, Division of Endocrinology and Metabolic Diseases, Catholic University, Rome, Italy
| | - Giacomo Tirabassi
- Division of Endocrinology, Department of Clinical and Molecular Sciences, Umberto I Hospital, Polytechnic University of Marche, Ancona, Italy
| | | | - Gianmaria Salvio
- Division of Endocrinology, Department of Clinical and Molecular Sciences, Umberto I Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Stavroula A Paschou
- Division of Endocrinology and Diabetes, "Aghia Sophia" Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Aristide Ferrara
- General Surgery and Transplantation Unit - "San Giovanni di Dio e Ruggi D'Aragona" University Hospital, Scuola Medica Salernitana, 84131, Salerno, Italy
| | - Enrico Russo
- General Surgery and Transplantation Unit - "San Giovanni di Dio e Ruggi D'Aragona" University Hospital, Scuola Medica Salernitana, 84131, Salerno, Italy
| | - Daniela Vicedomini
- General Surgery and Transplantation Unit - "San Giovanni di Dio e Ruggi D'Aragona" University Hospital, Scuola Medica Salernitana, 84131, Salerno, Italy
| | - Cerbone Vincenzo
- General Surgery and Transplantation Unit - "San Giovanni di Dio e Ruggi D'Aragona" University Hospital, Scuola Medica Salernitana, 84131, Salerno, Italy
| | - Andromachi Vryonidou
- Department of Endocrinology and Diabetes, Hellenic Red Cross Hospital, Athens, Greece
| | - Silvia Della Casa
- Institute of Medical Pathology, Division of Endocrinology and Metabolic Diseases, Catholic University, Rome, Italy
| | - Giancarlo Balercia
- Division of Endocrinology, Department of Clinical and Molecular Sciences, Umberto I Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Francesco Orio
- Endocrinology, Department of Sports Science and Wellness, "Parthenope" University Naples, Naples, Italy
| | - Paride De Rosa
- General Surgery and Transplantation Unit - "San Giovanni di Dio e Ruggi D'Aragona" University Hospital, Scuola Medica Salernitana, 84131, Salerno, Italy
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30
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Sharma AK, Masterson R, Holt SG, Tan SJ, Hughes PD, Chu M, Jayadeva P, Toussaint ND. Impact of cinacalcet pre-transplantation on mineral metabolism in renal transplant recipients. Nephrology (Carlton) 2016; 21:46-54. [PMID: 26072678 DOI: 10.1111/nep.12536] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2015] [Indexed: 11/30/2022]
Abstract
AIM Cinacalcet is effective in reducing parathyroid hormone (PTH) in patients on dialysis. Reports of biochemical profiles and other clinical outcomes in patients discontinuing cinacalcet at time of renal transplantation are limited. METHODS A retrospective study assessing markers of mineral metabolism, graft and patient outcomes in renal transplant recipients to determine differences in patients discontinuing cinacalcet (C+) compared with patients not treated with cinacalcet (C-) at time of transplantation. To allow for differences between groups in pre-transplant biochemical parameters, we also analysed a matched cohort of C- with C+ recipients (2:1), matched for age, calcium and PTH levels at transplantation. RESULTS Five hundred thirty-two recipients (460 C-, 72 C+), transplanted January 2006-December 2012, were analysed, mean age 48.0 ± 12.7 years and 64.3% were men. At a median 42.9 months follow up, there were 10 deaths (1.9%), 56 allograft loss (10.6%) and 5 parathyroidectomies post-transplant (0.8%). Median PTH immediately pre-transplant was higher in C+ versus C- (50.7(25.4-75.2) versus 28.3(13.9-49.7) pmol/L, P < 0.001). Twelve-month post-transplant PTH was reduced but higher in C+ (11.7(6.9-21.2) vs 7.2(4.6-11.2) pmol/L, P < 0.001). Mean calcium was higher for C+ versus C- at 12 months (2.50 ± 0.19 vs 2.43 ± 0.17 mmol/L, P < 0.001), with differences to 4 years post-transplant. No difference was seen in renal function, graft loss, post-transplant parathyroidectomy rate and mortality. In the matched cohort (144 C- vs 72 C+), similar findings were also seen. CONCLUSION Differences in mineral metabolism post-transplant are seen with cinacalcet pre-transplant compared with no cinacalcet. Transplant recipients discontinuing cinacalcet had higher post-transplant PTH and calcium although the clinical significance is unclear.
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Affiliation(s)
- Ashish K Sharma
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia
| | - Rosemary Masterson
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
| | - Stephen G Holt
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia
| | - Sven-Jean Tan
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia
| | - Peter D Hughes
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
| | - Melissa Chu
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
| | - Pavithra Jayadeva
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
| | - Nigel D Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia
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Çeltik A, Şen S, Yılmaz M, Demirci MS, Aşçı G, Tamer AF, Sarsık B, Hoşcoşkun C, Töz H, Ok E. The effect of hypercalcemia on allograft calcification after kidney transplantation. Int Urol Nephrol 2016; 48:1919-1925. [DOI: 10.1007/s11255-016-1391-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Accepted: 08/02/2016] [Indexed: 11/28/2022]
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Prevalence of Hypercalcaemia in a Renal Transplant Population: A Single Centre Study. Int J Nephrol 2016; 2016:7126290. [PMID: 27493801 PMCID: PMC4963578 DOI: 10.1155/2016/7126290] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 05/01/2016] [Accepted: 05/29/2016] [Indexed: 11/25/2022] Open
Abstract
Introduction. Postrenal transplant bone disease is a significant problem. Factors influencing postrenal transplant bone status include high dose acute and low dose long-term steroid use, persistent hypercalcaemia, and graft failure. In this study, we aimed to determine the prevalence of hypercalcaemia and to evaluate the risk factors for postrenal transplant hypercalcaemia in long-term renal transplant patients at our centre. Methods. This is a biochemical audit in which we studied renal transplant recipients from the Central Northern Adelaide Renal Transplant Services, South Australia. Inclusion criteria include kidney transplant patients with functioning graft since 1971 and at least 3 months after transplantation at the time of analysis. Hypercalcaemia was defined as persistently elevated serum corrected calcium greater than or equal to 2.56 mmol/L for three consecutive months. Results. 679 renal transplant recipients with a functioning graft were studied and 101 were hypercalcaemic between March 2011 and June 2011 (15%). 60% of the hypercalcaemic patients were male and 40% were female, with chronic glomerulonephritis (39%) being the commonest cause of their end stage kidney disease (ESKD). Prevalence was similar in those that had haemodialysis and peritoneal dialysis pretransplantation. Hypercalcaemia in the renal transplant population was not secondary to suboptimal allograft function but secondary to pretransplantation hyperparathyroidism with persistent high parathyroid hormone (PTH) levels after transplantation. Conclusion. There is a high prevalence of hypercalcaemia (15%) in renal transplant recipients. The predominant cause for hypercalcaemia is pretransplantation hyperparathyroidism. The magnitude of pretransplantation hyperparathyroidism is the major determinant for long-term parathyroid function rather than graft function or pretransplantation duration on dialysis or mode of dialysis.
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Wolf M, Weir MR, Kopyt N, Mannon RB, Von Visger J, Deng H, Yue S, Vincenti F. A Prospective Cohort Study of Mineral Metabolism After Kidney Transplantation. Transplantation 2016; 100:184-93. [PMID: 26177089 PMCID: PMC4683035 DOI: 10.1097/tp.0000000000000823] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Kidney transplantation corrects or improves many complications of chronic kidney disease, but its impact on disordered mineral metabolism is incompletely understood. The prevalence of posttransplant hyperparathyroidism was 86% at 12 months (PTH >65 pg/ml) but only 40% (PTH >130 mg/dL) in the absence of cinacalcet, vitamin D sterols, or parathyroidectomy. Intact fibroblast growth factor 23 decreased rapidly to G40 pg/ml by 3 months posttransplant. Supplemental digital content is available in the text.
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Affiliation(s)
- Myles Wolf
- 1 Division of Nephrology and Hypertension, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL. 2 Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD. 3 Lehigh Valley Hospital, Allentown, PA. 4 University of Alabama at Birmingham, Birmingham, AL. 5 The Ohio State University Medical Center, Columbus, OH. 6 Amgen Inc., Thousand Oaks, CA. 7 Kidney Transplant Service, University of California San Francisco, San Francisco, CA
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Rapid calcitriol increase and persistent calcidiol insufficiency in the first 6 months after kidney transplantation. Nucl Med Commun 2015; 36:489-93. [PMID: 25603274 DOI: 10.1097/mnm.0000000000000265] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Vitamin D deficiency or insufficiency is prevalent in kidney transplant recipients. Little is known about post-transplantation changes in vitamin D forms, which are essential for bone health and other health outcomes. The aim was to measure the levels of calcidiol and calcitriol during the first 6 months after kidney transplantation and examine their relation with other bone mineral metabolic parameters. PATIENTS AND METHODS A prospective study was performed on 98 patients recruited between April 2010 and June 2011. Calcidiol and calcitriol levels were measured at baseline and at days 15, 30, 90, and 180 after kidney transplantation. RESULTS Serum calcidiol levels remained persistently low: 14.3 (9-22) ng/ml at baseline and 16.3 (10.1-20.6) ng/ml at 6 months (P=0.641). At 6 months, calcidiol levels showed an inverse correlation with simultaneously measured parathyroid hormone levels. Calcidiol showed a trend to be higher in patients transplanted in spring but with no statistically significant difference. Calcitriol levels increased from 17 (13-23.7) pg/ml at baseline to 24 (16-32) pg/ml (P=0.002) in the first 2 weeks after transplantation and reached 37 (25-50) pg/ml (P=0.000) after 6 months. During the follow-up, calcitriol levels showed a significant inverse correlation with baseline fibroblast growth factor-23 levels. At month 6, calcitriol levels were inversely correlated with baseline fibroblast growth factor-23 levels and directly correlated with calcidiol levels. CONCLUSION In most patients, calcidiol levels remain low 6 months after kidney transplantation, whereas calcitriol levels rapidly return to normal. Lower calcidiol blood levels promoted lower calcitriol blood levels and higher parathyroid hormone concentrations.
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Wong J, Tan MZW, Chandran M. Fifty shades of gray: Bone disease in renal transplantation. PROCEEDINGS OF SINGAPORE HEALTHCARE 2015. [DOI: 10.1177/2010105815611808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Kidney transplantation is the renal replacement therapy of choice for patients with end stage renal disease. Advances in technology, surgical techniques and pharmacotherapy have improved renal allograft survival. Increasingly, we are seeing long term side effects related to renal transplantation, bone disease being a major one amongst them. Renal transplant patients have a higher risk of fragility fractures even when compared to those who remain on dialysis. This is likely to be related to pre-existing underlying bone disease and the emergence of new metabolic bone problems post-transplant. Conditions such as persistent hyperparathyroidism and the use of certain immunosuppressive agents have a deleterious effect on the post renal transplant bone. Remarkable advances in the field of metabolic bone research have been made in the last decade and newer imaging techniques, biomarkers and therapeutic options are now available for osteoporosis in the general population. Interest is being focused on attempting to extrapolate these new discoveries to the management of bone disease post renal transplant. This review will briefly describe the metabolic bone changes that occur after transplantation and will provide an update on the currently available investigative options and therapeutic strategies for the management of post renal transplant bone disease.
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Affiliation(s)
- Jiunn Wong
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | | | - Manju Chandran
- Department of Endocrinology, Singapore General Hospital, Singapore
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Saber A, Fotuhi F, Rostami Z, Einollahi B, Nemati E. Vitamin D Levels After Kidney Transplantation and the Risk of Cytomegalovirus Infection. Nephrourol Mon 2015; 7:e29677. [PMID: 26866004 PMCID: PMC4744636 DOI: 10.5812/numonthly.29677] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Revised: 05/26/2015] [Accepted: 06/03/2015] [Indexed: 12/31/2022] Open
Abstract
Background: Some studies reported an association between low levels of vitamin D and the risk of infections, especially viral infections. Kidney transplant patients are at risk of opportunistic infections; however, no study has been conducted on the association between vitamin D levels and the risk of CMV infection. Objectives: The aim of this study was to compare the level of vitamin D in two groups of patients with and without CMV infection within four months after the transplantation. Moreover, we aimed to find a relation between vitamin D level, before and after transplantation in each group. Patients and Methods: This prospective cohort study was conducted in Baqiyatallah hospital in Tehran in 2013. A total of 82 kidney transplant patients were enrolled and vitamin D levels were measured in them before transplantation. The kidney transplant patients had been followed up for four months and monitored for the presence of cytomegalovirus antigen (CMV Ag) in their blood. In patients with positive CMV Ag, vitamin D level was measured again when they became positive but in other patients it was measured at the end of follow-up; at the end, characteristics of patients and vitamin D levels were compared between the two groups. Results: Of all, 40 patients were CMV Ag positive and 42 patients were negative. In most patients transplanted organs were taken from cadaver (66%) and the most common type of dialysis was hemodialysis (92%). Most participants did not undergo antithymocyte globulin therapy (69%) and pulse corticosteroid therapy (83%). Vitamin D level before transplantation was 17.2 ± 11.6 ng/mL. In patients with positive results or at the end of follow-up in patients without CMV Ag, vitamin D level was 16.3 ± 11.4 ng/mL. Only 11% of kidney transplant patients, within four months after transplantation, had a normal level of vitamin D (> 30 ng/mL). There was no significant difference between the two groups for patients’ characteristics (P > 0.05). Vitamin D levels, before transplantation and at the time of detecting CMV Ag or at the end of follow-up period in patients without CMV, were not significantly different between the two groups (P > 0.05). However, vitamin D levels decreased in patients with CMV, while it increased in CMV Ag negative patients, which was statistically significant (P = 0.037). Conclusions: Only 11% of kidney transplant patients, even with a successful transplantation of the kidney and with an acceptable performance of the transplanted kidney, had an adequate level of vitamin D. Although, we did not find any significant association between vitamin D levels and CMV infection during a 4-month follow-up after kidney transplantation. It was observed that, compared with the time before transplantation, vitamin D levels decreased in patients with CMV, while it increased in CMV negative patients.
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Affiliation(s)
- Azadeh Saber
- Department of Nephrology, Kerman University of Medical Sciences, Kerman, IR Iran
| | - Farzaneh Fotuhi
- Department of Nephrology, Rajaei Cardiovascular, Medical & Research Center, Tehran, IR Iran
| | - Zohre Rostami
- Department of Nephrology, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
- Corresponding author: Zohre Rostami, Department of Nephrology, Baqiyatallah University of Medical Sciences, Tehran, IR Iran. Tel: +98-218126, E-mail:
| | - Behzad Einollahi
- Department of Nephrology, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| | - Eghlim Nemati
- Department of Nephrology, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
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Gulleroglu K, Baskin E, Moray G, Haberal M. Low-Grade Persistent Hyperparathyroidism After Pediatric Renal Transplant. EXP CLIN TRANSPLANT 2015; 14:294-8. [PMID: 26581346 DOI: 10.6002/ect.2014.0157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Hyperparathyroidism, a frequent complication of chronic kidney disease, persists after renal transplant. Our aims were to examine the status of parathyroid hormone levels and to determine the clinical and biochemical risk factors of persistent hyperparathyroidism after transplant. MATERIALS AND METHODS Our study included 44 pediatric renal transplant recipients with stable graft function. Median follow-up after transplant was 17.5 months (range, 12-126 mo). Patients did not receive routine vitamin D or calcium supplements after transplant, and none had undergone previous parathyroidectomy. Bone mineral densitometry of the lumbar spine was measured. RESULTS Fifteen patients (34%) had parathyroid hormone levels greater than 70 pg/mL (normal range, 10-70 pg/mL). Duration of dialysis before transplant was longer in patients with persistent hyperparathyroidism. Mean serum bicarbonate levels were significantly lower in patients with persistent hyperparathyroidism than in patients without persistent hyperparathyroidism after transplant. A significant negative correlation was noted between parathyroid hormone level and serum bicarbonate level. Another significant negative correlation was shown between parathyroid hormone level and z score. CONCLUSIONS We found that persistent hyperparathyroidism is related to longer dialysis duration, lower serum bicarbonate level, and lower z score. Pretransplant dialysis duration is an important predictor of persistent hyperparathyroidism. Early identification of factors that contribute to persistent hyperparathyroidism after transplant could lead to treatment strategies to minimize or prevent its detrimental effects on bone health and growth in pediatric transplant recipients.
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Affiliation(s)
- Kaan Gulleroglu
- From the Pediatric Nephrology Department, Baskent University, Ankara, Turkey
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Lorenz K, Bartsch DK, Sancho JJ, Guigard S, Triponez F. Surgical management of secondary hyperparathyroidism in chronic kidney disease--a consensus report of the European Society of Endocrine Surgeons. Langenbecks Arch Surg 2015; 400:907-27. [PMID: 26429790 DOI: 10.1007/s00423-015-1344-5] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 09/18/2015] [Indexed: 12/28/2022]
Abstract
BACKGROUND Despite advances in the medical management of secondary hyperparathyroidism due to chronic renal failure and dialysis (renal hyperparathyroidism), parathyroid surgery remains an important treatment option in the spectrum of the disease. Patients with severe and complicated renal hyperparathyroidism (HPT), refractory or intolerant to medical therapy and patients with specific requirements in prospect of or excluded from renal transplantation may require parathyroidectomy for renal hyperparathyroidism. METHODS Present standard and actual controversial issues regarding surgical treatment of patients with hyperparathyroidism due to chronic renal failure were identified, and pertinent literature was searched and reviewed. Whenever applicable, evaluation of the level of evidence concerning diagnosis and management of renal hyperparathyroidism according to standard criteria and recommendation grading were employed. Results were discussed at the 6th Workshop of the European Society of Endocrine Surgeons entitled Hyperparathyroidism due to multiple gland disease: An evidence-based perspective. RESULTS Presently, literature reveals scant data, especially, no prospective randomized studies to provide sufficient levels of evidence to substantiate recommendations for surgery in renal hyperparathyroidism. Appropriate surgical management of renal hyperparathyroidism involves standard bilateral exploration with bilateral cervical thymectomy and a spectrum of four standardized types of parathyroid resection that reveal comparable outcome results with regard to levels of evidence and recommendation. Specific patient requirements may favour one over the other procedure according to individualized demands. CONCLUSIONS Surgery for patients with renal hyperparathyroidism in the era of calcimimetics continues to play an important role in selected patients and achieves efficient control of hyperparathyroidism. The overall success rate and long-term control of renal hyperparathyroidism and optimal handling of postoperative metabolic effects also depend on the timely indication, individually suitable type of parathyroid resection and specialized endocrine surgery.
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Affiliation(s)
- Kerstin Lorenz
- Department of General-, Visceral-, and Vascular Surgery, Martin-Luther University of Halle-Wittenberg, Ernst-Grube-Str. 40, Halle (Saale), 06120, Germany.
| | - Detlef K Bartsch
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Baldingerstraße 1, Marburg, 35043, Germany.
| | - Juan J Sancho
- Department of General Surgery, Endocrine Surgery Unit, Hospital del Mar, Universitat Autònoma de Barcelona, Passeig Marítim 25-29, Barcelona, 08003, Spain.
| | - Sebastien Guigard
- Department of Thoracic and Endocrine Surgery, University Hospitals of Geneva, Switzerland, Rue Gabrielle Perret-Gentil 4, 14, Geneva, 1211, Switzerland.
| | - Frederic Triponez
- Chirurgie thoracique et endocrinienne, Hôpitaux Universitaires de Genève, Rue Gabrielle Perret-Gentil 4, 14, Geneva, 1211, Switzerland.
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Borrego Utiel FJ, Bravo Soto JA, Merino Pérez MJ, González Carmelo I, López Jiménez V, García Álvarez T, Acosta Martínez Y, Mazuecos Blanca MA. Effect of paricalcitol on mineral bone metabolism in kidney transplant recipients with secondary hyperparathyroidism. Nefrologia 2015; 35:363-73. [PMID: 26306956 DOI: 10.1016/j.nefro.2015.06.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 01/16/2015] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION Secondary hyperparathyroidism is highly prevalent in kidney transplant recipients, and commonly results in hypercalcaemia; an association to osteopenia and bone fractures has also been observed. Paricalcitol has proved effective to control secondary hyperparathyroidism in chronic kidney disease in both dialysed and non-dialysed patients, with a low hypercalcaemia incidence. Currently available experience on paricalcitol use in kidney transplant recipients is scarce. Our main aim was to show the effect of paricalcitol on mineral bone metabolism in kidney transplant recipients with secondary hyperparathyroidism. MATERIAL AND METHODS A retrospective multicentre study in kidney transplant recipients aged>18 years with a 12-month or longer post-transplantation course, stable renal function, having received paricalcitol for more than 12 months, with available clinical follow-up for a 24-month period. RESULTS A total of 69 patients with a 120 ± 92-month post-transplantation course were included. Baseline creatinine was 2.2 ± 0.9 mg/dl y GFR-MDRD was 36 ± 20 ml/min/1.73 m(2). Paricalcitol doses were gradually increased during the study: baseline 3.8 ± 1.9 μg/week, 12 months 5.2 ± 2.4 μg/week; 24 months 6.0 ± 2.9 μg/week (P<.001). Serum PTH levels showed a significant fast decline: baseline 288 ± 152 pg/ml; 6 months 226 ± 184 pg/ml; 12 months 207 ± 120; 24 months 193 ± 119 pg/ml (P<.001). Reduction from baseline PTH was ≥30% in 42.4% of patients at 12 months y in 65.2% of patients at 24 months. Alkaline phosphatase showed a significant decrease in first 6 months followed by a plateau: baseline 92 ± 50 IU/l; 6 months 85 ± 36 IU/l, 12 months 81 ± 39 IU/l (P<.001). Overall, no changes were observed in serum calcium and phosphorus, and in urine calcium excretion. PTH decline was larger in patients with higher baseline levels. Patients with lower baseline calcium levels showed significantly increased levels (mean increase was 0.5-0.6 mg/dl) but still within normal range, whereas patients with baseline calcium>10mg/dl showed gradually decreasing levels. Fifteen (21.7%) patients had received prior calcitriol therapy. When shifted to paricalcitol, such patients required paricalcitol doses significantly larger than those not having received calcitriol. Paricalcitol was used concomitantly to cinacalcet in 11 patients with significant PTH reductions being achieved; clinical course was similar to other patients and paricalcitol doses were also similar. CONCLUSIONS Paricalcitol is an effective therapy for secondary hyperparathyroidism in kidney transplant recipients. Overall, no significant changes were observed in calcium and phosphorus levels or urinary excretion. Patients having previously received calcitriol required higher paricalcitol doses. When used in patients receiving cinacalcet, paricalcitol results in a significant PTH fall, with paricalcitol doses being similar to those used in patients not receiving cinacalcet.
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Abstract
BACKGROUND Alterations in bone mineral metabolism occur when kidney function declines and often continue after transplantation. We investigated long-term changes in bone mineral density (BMD) among kidney transplant recipients undergoing routine clinical BMD monitoring and management. METHODS We identified adults receiving a kidney transplant in the province of Manitoba, Canada (1996-2011) who had greater than or equal to 2 posttransplant dual energy X-ray absorptiometry examinations. Bone mineral density was expressed as Z scores (standard deviation above/below sex-matched and age-matched reference data). The main outcome was the change in BMD. RESULTS A total of 326 kidney transplant recipients were included (mean age, 45 years; 61% men). Recipients were followed up for an average of 8.2 years (766 follow-up dual energy X-ray absorptiometry measurements). At baseline (first scan; median, 0.5 years after transplantation), bone density was slightly below average for age and sex (mean Z scores: lumbar spine, -0.4 ± 1.6; femoral neck, -0.7 ± 1.1; total hip, -0.7 ± 1.1). At the second scan (mean, 2.7 years after first scan), mean bone density Z scores have increased (lumbar spine, -0.2 ± 1.6; femoral neck, -0.6 ± 1; total hip, -0.6 ± 1.1; matched, P < 0.01 at all sites). The only factor associated with a significant BMD change at all sites was osteoporosis treatment (BMD increase). Even after restricting the analysis to recipients who had not received osteoporosis treatment, final mean bone density (mean, 8.2 years after first scan) was average for age and sex (lumbar spine, +0.7 ± 1.6; femoral neck, -0.1 ± 1.1; total hip, 0.0 ± 1.1). CONCLUSION With routine BMD monitoring and management, posttransplant bone density typically remains stable or improves with mean values that are average for age and sex.
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Chonchol M, Wüthrich RP. Potential future uses of calcimimetics in patients with chronic kidney disease. NDT Plus 2015; 1:i36-i41. [PMID: 25983955 PMCID: PMC4421155 DOI: 10.1093/ndtplus/sfm043] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2007] [Accepted: 09/10/2007] [Indexed: 11/23/2022] Open
Abstract
Cinacalcet has proven effective in the treatment of secondary hyperparathyroidism (SHPT) in dialysis patients, and it may also have benefits in stage 3 and 4 chronic kidney disease (CKD). The efficacy of cinacalcet in the treatment of SHPT was investigated in a study of 54 patients with stage 3 and 4 CKD not receiving dialysis. A significant number of these patients achieved at least a 30% reduction in parathyroid hormone (PTH) from baseline with cinacalcet therapy compared with placebo (56% versus 19%; P = 0.006). Another potential use of cinacalcet is in the treatment of persistent hyperparathyroidism (HPT) after kidney transplantation. The pathophysiologic considerations for persistent HPT in patients who have undergone renal transplantation are different from those in stage 3 and 4 CKD. Post-transplant patients with normal graft function often present with hypercalcaemia, low serum phosphorus and persistently elevated levels of PTH. In eight small open-label studies including a total of 83 patients with persistent HPT after successful kidney transplantation, cinacalcet treatment effectively corrected hypercalcaemia and significantly reduced elevated PTH levels. These studies suggest that cinacalcet therapy is an effective therapy in controlling hyperparathyroidism in patients with stage 3 and 4 CKD and in post-transplant patients with persistent hyperparathyroidism.
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Affiliation(s)
- Michel Chonchol
- University of Colorado Health Sciences Center , Denver, CO , USA
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Bleskestad IH, Bergrem H, Leivestad T, Hartmann A, Gøransson LG. Parathyroid hormone and clinical outcome in kidney transplant patients with optimal transplant function. Clin Transplant 2014; 28:479-86. [PMID: 25649861 DOI: 10.1111/ctr.12341] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND The aim of the study was to investigate whether serum levels of intact parathyroid hormone (iPTH) are associated with an increased risk of cardiovascular events, graft loss, or mortality in kidney transplant patients with optimal transplant function. METHODS From the Norwegian Renal Registry, we identified 522 patients who received a first kidney transplant from 2001 to 2008 with optimal transplant function defined as an estimated glomerular filtration rate (eGFR)≥60 mL/min/1.73 m2, more than one yr after transplantation. Cox's proportional hazard models were used to assess the association between iPTH measured 10 wk after transplantation and the composite endpoint. The estimates were adjusted for age, gender, serum calcium, serum phosphate, diabetes mellitus, cardiovascular disease, and time on dialysis prior to transplantation. RESULTS Median follow-up time was 3.9 yr (interquartile range, IQR: 2.0-6.0 yr). Patients in the third iPTH quartile (9.3-14.4 pM) had the lowest risk for reaching the composite endpoint. Patients in the fourth iPTH quartile (>14.4 pM) had an increased risk compared to those in the third quartile (HR: 2.60, 95% CI: 1.10-6.16, p=0.03). CONCLUSION In patients with optimal transplant function, iPTH levels are associated with a clinical outcome consisting of cardiovascular events, graft loss, and all-cause mortality.
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Affiliation(s)
- Inger H Bleskestad
- Department of Medicine, Stavanger University Hospital, Stavanger, Norway
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Muirhead N, Zaltman JS, Gill JS, Churchill DN, Poulin-Costello M, Mann V, Cole EH. Hypercalcemia in renal transplant patients: prevalence and management in Canadian transplant practice. Clin Transplant 2013; 28:161-5. [PMID: 24329899 DOI: 10.1111/ctr.12291] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2013] [Indexed: 12/11/2022]
Abstract
Hypercalcemia, occurring in up to 25% of patients within 12 months following renal transplantation, and persistent hyperparathyroidism were evaluated following renal transplantation, by retrospective chart review of 1000 adult patients transplanted between January 1, 2003 and January 31, 2008 with at least six months follow-up. Serum calcium, parathyroid hormone, and phosphate levels were recorded at 12, 24, 36, and 48 months. Average follow-up was 766 (535) d (mean (SD); median 668 d). Majority were first transplants (85%); deceased donor 57%. Point prevalence of hypercalcemia (serum Ca(2+) > 2.6 mM) was 16.6% at month 12, 13.6% at month 24, 9.5% at month 36, and 10.1% at month 48. Point prevalence of serum parathyroid hormone (PTH) > 10 pM was 47.6% at month 12, 51.1% at month 24, 43.4% at month 36, and 39.3% at month 48. Estimated glomerular filtration rate (GFR) was maintained throughout and was not different between patients with or without hypercalcemia or elevated PTH. Cinacalcet was prescribed in 12% of patients with hypercalcemia and persistent hyperparathyroidism; parathyroidectomy was performed in 112/1000 patients, 15 post-transplant. Persistent hyperparathyroidism, often accompanied by hypercalcemia, is common following successful renal transplantation, but the lack of clear management suggests the need for further study and development of evidence-based guidelines.
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Affiliation(s)
- N Muirhead
- London Health Sciences Centre, London, ON, Canada
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FGF23 and mineral metabolism in the early post-renal transplantation period. Pediatr Nephrol 2013; 28:2207-15. [PMID: 23852336 PMCID: PMC3796035 DOI: 10.1007/s00467-013-2547-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 05/08/2013] [Accepted: 06/07/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND The relationship between fibroblast growth factor 23 (FGF23) and vitamin D production and catabolism post-renal transplantation has not been characterized. METHODS Circulating creatinine, calcium, phosphorus, albumin, parathyroid hormone, FGF23, and 1,25(OH)2 vitamin D (calcitriol) values were obtained pre-transplantation, daily post-operatively for 5 days, and at 6 months post-transplantation in 44 patients aged 16.4 ± 0.4 years undergoing renal transplantation at UCLA from 1 August 2005 through to 30 April 2007. 25(OH) Vitamin D and 24,25(OH)2 vitamin D concentrations were obtained at baseline and on post-operative days 5 and 180, and urinary concentrations of creatinine, phosphorus, and FGF23 were measured on post-operative days 1, 3, 5, and 180. RESULTS Circulating phosphate concentrations declined more rapidly and the fractional excretion of phosphorus was higher in the first week post-transplantation in subjects with higher FGF23 values. Fractional excretion of FGF23 was low at all time-points. Circulating 1,25(OH)2 vitamin D levels rose more rapidly and were consistently higher in patients with lower FGF23 values; however, 25(OH) vitamin D and 24,25(OH)2 vitamin D values were unrelated to FGF23 concentrations. CONCLUSIONS Inhibition of renal 1α-hydroxylase, rather than stimulation of 24-hydroxylase, may primarily contribute to the relationship between FGF23 values and calcitriol. The rapid decline in FGF23 levels post-transplantation in our patient cohort was not mediated solely by the filtration of intact FGF23 by the new kidney.
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Perrin P, Caillard S, Javier RM, Braun L, Heibel F, Borni-Duval C, Muller C, Olagne J, Moulin B. Persistent hyperparathyroidism is a major risk factor for fractures in the five years after kidney transplantation. Am J Transplant 2013; 13:2653-63. [PMID: 24034142 DOI: 10.1111/ajt.12425] [Citation(s) in RCA: 104] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 07/02/2013] [Accepted: 07/03/2013] [Indexed: 01/25/2023]
Abstract
The risk of fractures after kidney transplantation is high. Hyperparathyroidism frequently persists after successful kidney transplantation and contributes to bone loss, but its impact on fracture has not been demonstrated. This longitudinal study was designed to evaluate hyperparathyroidism and its associations with mineral disorders and fractures in the 5 posttransplant years. We retrospectively analyzed 143 consecutive patients who underwent kidney transplantation between August 2004 and April 2006. The biochemical parameters were determined at transplantation and at 3, 12 and 60 months posttransplantation, and fractures were recorded. The median intact parathyroid hormone (PTH) level was 334 ng/L (interquartile 151-642) at the time of transplantation and 123 ng/L (interquartile 75-224) at 3 months. Thirty fractures occurred in 22 patients. The receiver operating characteristic (ROC) curve analysis for PTH at 3 months (area under the ROC curve = 0.711, p = 0.002) showed that a good threshold for predicting fractures was 130 ng/L (sensitivity = 81%, specificity = 57%). In a multivariable analysis, independent risk factors for fracture were PTH >130 ng/L at 3 months (adjusted hazard ratio [AHR] = 7.5, 95% CI 2.18-25.50), and pretransplant osteopenia (AHR = 2.7, 95% CI 1.07-7.26). In summary, this study demonstrates for the first time that persistent hyperparathyroidism is an independent risk factor for fractures after kidney transplantation.
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Affiliation(s)
- P Perrin
- Nephrology-Transplantation Department, University Hospital, Strasbourg, France
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Recovery versus persistence of disordered mineral metabolism in kidney transplant recipients. Semin Nephrol 2013; 33:191-203. [PMID: 23465505 DOI: 10.1016/j.semnephrol.2012.12.019] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In patients with end-stage renal disease, successful renal transplantation improves the quality of life and increases survival, as compared with long-term dialysis treatment. Although it long has been believed that successful kidney transplantation to a large extent solves the problem of chronic kidney disease-mineral and bone disorders (CKD-MBD), increasing evidence indicates that it only changes the phenotype of CKD-MBD. Posttransplant CKD-MBD reflects the effects of immunosuppression, previous CKD-MBD persisting after transplantation, and de novo CKD-MBD. A major and often-underestimated problem after successful renal transplantation is persistent hyperparathyroidism. Besides contributing to posttransplant hypercalcemia and hypophosphatemia, persistent hyperparathyroidism may be involved in the pathogenesis of allograft dysfunction (nephrocalcinosis), progression of vascular calcification, and bone disease (uncoupling of bone formation and bone resorption and bone mineral density loss) in renal transplant recipients. Similar to nontransplanted patients, CKD-MBD has a detrimental impact on (cardiovascular) mortality and morbidity. Additional studies urgently are needed to get more insights into the pathophysiology of posttransplant CKD-MBD. These new insights will allow for a more targeted and causal therapeutic approach.
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Hiemstra TF, Brown AJD, Chaudhry AN, Walsh M. Association of calcium, phosphate and parathyroid hormone with renal allograft function: a retrospective cohort study. Am J Nephrol 2013; 37:339-45. [PMID: 23548209 DOI: 10.1159/000348376] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 01/24/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Significant variations in postoperative levels of parathyroid hormone (PTH), calcium and phosphate exist after renal transplantation, but whether they affect allograft function is unknown. We investigated the association between early post-transplant levels of PTH, calcium and phosphate and graft function. METHODS We performed a single-centre cohort study of renal transplant recipients from Addenbrooke's Hospital, Cambridge, between April 1997 and March 2007, evaluating the association between plasma calcium, phosphate and PTH 1 month after transplantation and change in epidermal growth factor receptor (eGFR) in the first 12 months after transplantation (estimated using the Modification of Diet in Renal Disease Study equation). Differences in eGFR between 26 and 52 weeks after transplantation were computed using mixed effects linear regression models for repeated measures of eGFR, while adjusting for sociodemographic and biochemical variables. RESULTS Three hundred and forty-three patients were eligible for study. The mean age (standard deviation) at transplant was 43 years (13 years). Between 30 and 90 days after transplantation, the median (25th-75th percentile) eGFR was 33 (26-50) ml/min/1.73 m(2), the mean calcium level was 2.4 (0.17) mmol/l and the mean phosphate level was 0.78 (0.23) mmol/l. There was a significant interaction between calcium and phosphate levels (p = 0.006). In patients with low levels of phosphate, higher levels of calcium were associated with declining eGFR over time. However, in patients with a high phosphate level, higher calcium was associated with improved eGFR. CONCLUSIONS Higher serum calcium in patients with low serum phosphate after transplantation is associated with a decline in graft function during the first year after transplantation. Disorders of mineral metabolism after transplant may represent an important therapeutic target to preserve allograft function.
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Affiliation(s)
- Thomas F Hiemstra
- Division of Renal Medicine, Department of Medicine, University of Cambridge, Cambridge, UK
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Bhat S, Hegde S, Bellovich K, El-Ghoroury M. Complete resolution of calciphylaxis after kidney transplantation. Am J Kidney Dis 2013; 62:132-4. [PMID: 23433466 DOI: 10.1053/j.ajkd.2012.12.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2012] [Accepted: 12/11/2012] [Indexed: 11/11/2022]
Abstract
Calciphylaxis, a life-threatening and disabling complication in patients with end-stage renal disease, occurs most frequently in those treated with maintenance dialysis, whether it be hemodialysis or peritoneal dialysis. The impact of kidney transplantation on calciphylaxis lesions is not clear. The general consensus is to treat calciphylaxis adequately prior to transplantation with either medical therapy or parathyroidectomy, as indicated. We describe the case of a patient on peritoneal dialysis therapy who had severe calciphylaxis lesions that failed to resolve upon pretransplantation medical treatment and that then resolved after kidney transplantation.
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Affiliation(s)
- Samrat Bhat
- St John Hospital and Medical Center, Detroit, MI, USA.
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Abstract
PURPOSE OF REVIEW Mineral and bone disorders (MBDs), inherent complications of moderate and advanced chronic kidney disease, occur frequently in kidney transplant recipients. However, much confusion exists about the clinical application of diagnostic tools and preventive or treatment strategies to correct bone loss or mineral disarrays in transplanted patients. We have reviewed the recent evidence about prevalence and consequences of MBD in kidney transplant recipients and examined diagnostic, preventive and therapeutic options to this end. RECENT FINDINGS Low turnover bone disease occurs more frequently after kidney transplantation according to bone biopsy studies. The risk of fracture is high, especially in the first several months after kidney transplantation. Alterations in minerals (calcium, phosphorus and magnesium) and biomarkers of bone metabolism (parathyroid hormone, alkaline phosphatase, vitamin D and FGF-23) are observed with varying impact on posttransplant outcomes. Calcineurin inhibitors are linked to osteoporosis, whereas steroid therapy may lead to both osteoporosis and varying degrees of osteonecrosis. Sirolimus and everolimus might have a bearing on osteoblast proliferation and differentiation or decreasing osteoclast-mediated bone resorption. Selected pharmacologic interventions for the treatment of MBD in transplant patients include steroid withdrawal, and the use of bisphosphonates, vitamin D derivatives, calcimimetics, teriparatide, calcitonin and denosumab. SUMMARY MBD following kidney transplantation is common and characterized by loss of bone volume and mineralization abnormalities, often leading to low turnover bone disease. Although there are no well established therapeutic approaches for management of MBD in renal transplant recipients, clinicians should continue individualizing therapy as needed.
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Peeters MJ, van Zuilen AD, van den Brand JAJG, Blankestijn PJ, ten Dam MAGJ, Wetzels JFM. Differences between hospitals in attainment of parathyroid hormone treatment targets in chronic kidney disease do not reflect differences in quality of care. BMC Nephrol 2012; 13:82. [PMID: 22867424 PMCID: PMC3467173 DOI: 10.1186/1471-2369-13-82] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Accepted: 07/27/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Transparency in quality of care (QoC) is stimulated and hospitals are compared and judged on the basis of indicators of performance on specific treatment targets. In patients with chronic kidney disease, QoC differed significantly between hospitals. In this analysis we explored additional parameters to explain differences between centers in attainment of parathyroid hormone (PTH) treatment targets. METHODS Using MASTERPLAN baseline data, we selected one of the worst (center A) and one of the best (center B) performing hospitals. Differences between the two centers were analyzed from the year prior to start of the MASTERPLAN study until the baseline evaluation. Determinants of PTH were assessed. RESULTS 101 patients from center A (median PTH 9.9 pmol/l, in 67 patients exceeding recommended levels) and 100 patients from center B (median PTH 6.5 pmol/l, in 34 patients exceeding recommended levels), were included. Analysis of clinical practice did not reveal differences in PTH management between the centers. Notably, hyperparathyroidism resulted in a change in therapy in less than 25% of patients. In multivariate analysis kidney transplant status, MDRD-4, and treatment center were independent predictors of PTH. However, when MDRD-6 (which accounts for serum urea and albumin) was used instead of MDRD-4, the center effect was reduced. Moreover, after calibration of the serum creatinine assays treatment center no longer influenced PTH. CONCLUSIONS We show that differences in PTH control between centers are not explained by differences in treatment, but depend on incomparable patient populations and laboratory techniques. Therefore, results of hospital performance comparisons should be interpreted with great caution.
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Affiliation(s)
- Mieke J Peeters
- Department of Nephrology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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