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Ferreira AC, Mendes M, Silva C, Cotovio P, Aires I, Navarro D, Caeiro F, Salvador R, Correia B, Cabral G, Nolasco F, Ferreira A. Biochemical Clusters as Substitutes of Bone Biopsies in Kidney Transplant Patients. Calcif Tissue Int 2024; 114:267-275. [PMID: 38253933 DOI: 10.1007/s00223-023-01173-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 12/09/2023] [Indexed: 01/24/2024]
Abstract
Bone and mineral metabolism abnormalities are frequent in kidney transplant recipients and have been associated with cardiovascular morbidity. The primary aim of this study was to analyse the association between routine clinically available biochemical evaluation, non-routine histomorphometric bone evaluation, and vascular disease in kidney transplanted patients. A cross-sectional analysis was performed on 69 patients, 1-year after kidney transplantation. Laboratory analysis, radiography of hands and pelvis, bone biopsy, bone densitometry, and coronary CT were performed. One-year post-transplantation, nearly one-third of the patients presented with hypercalcemia, 16% had hypophosphatemia, 39.3% had iPTH levels > 150 pg/mL, 20.3% had BALP levels > 40 U/L, and 26.1% had hypovitaminosis D. Evaluation of extraosseous calcifications revealed low Adragão and Agatston scores. We divided patients into three clusters, according to laboratory results routinely used in clinical practice: hypercalcemia and hyperparathyroidism (Cluster1); hypercalcemia and high BALP levels (Cluster2); hypophosphatemia and vitamin D deficiency (Cluster 3). Patients in clusters 1 and 2 had higher cortical porosity (p = 0.001) and osteoid measurements, although there was no difference in the presence of abnormal mineralization, or low volume. Patients in cluster 2 had a higher BFR/BS (half of the patients in cluster 2 had high bone turnover), and most patients in cluster 1 had low or normal bone turnover. Cluster 3 has no differences in volume, or turnover, but 60% of the patients presented with pre-osteomalacia. All three clusters were associated with high vascular calcifications scores. Vascular calcifications scores were not related to higher bone mineral density. Instead, an association was found between a higher Adragão score and the presence of osteoporosis at the femoral neck (p = 0.008). In conclusion, inferring bone TMV by daily clinical biochemical analysis can be misleading, and bone biopsy is important for assessing both bone turnover and mineralization after kidney transplantation, although hypophosphatemia combined with vitamin D deficiency is associated with abnormal mineralization. The presence of hypercalcemia with high levels of PTH or high levels of BALP, or hypophosphatemia and vitamin D deficiency should remind us to screen vascular calcification status of patients.Clinical Research: ClinicalTrials.gov ID NCT02751099.
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Affiliation(s)
- Ana Carina Ferreira
- Nephrology Department, Hospital Curry Cabral | CHULC, Rua da Beneficência nº8, 1050-099, Lisbon, Portugal.
- Nova Medical School, Lisbon, Portugal.
| | - Marco Mendes
- Nephrology Department, Hospital Curry Cabral | CHULC, Rua da Beneficência nº8, 1050-099, Lisbon, Portugal
- Nova Medical School, Lisbon, Portugal
| | - Cecília Silva
- Nephrology Department, Hospital Curry Cabral | CHULC, Rua da Beneficência nº8, 1050-099, Lisbon, Portugal
| | - Patrícia Cotovio
- Nephrology Department, Hospital Curry Cabral | CHULC, Rua da Beneficência nº8, 1050-099, Lisbon, Portugal
| | - Inês Aires
- Nephrology Department, Hospital Curry Cabral | CHULC, Rua da Beneficência nº8, 1050-099, Lisbon, Portugal
- Nova Medical School, Lisbon, Portugal
| | - David Navarro
- Nephrology Department, Hospital Curry Cabral | CHULC, Rua da Beneficência nº8, 1050-099, Lisbon, Portugal
| | - Fernando Caeiro
- Nephrology Department, Hospital Curry Cabral | CHULC, Rua da Beneficência nº8, 1050-099, Lisbon, Portugal
- Nova Medical School, Lisbon, Portugal
| | - Rute Salvador
- Nephrology Department, Hospital Curry Cabral | CHULC, Rua da Beneficência nº8, 1050-099, Lisbon, Portugal
- Nova Medical School, Lisbon, Portugal
| | - Bruna Correia
- Nephrology Department, Hospital Curry Cabral | CHULC, Rua da Beneficência nº8, 1050-099, Lisbon, Portugal
- Nova Medical School, Lisbon, Portugal
| | - Guadalupe Cabral
- Nephrology Department, Hospital Curry Cabral | CHULC, Rua da Beneficência nº8, 1050-099, Lisbon, Portugal
- Nova Medical School, Lisbon, Portugal
| | - Fernando Nolasco
- Nephrology Department, Hospital Curry Cabral | CHULC, Rua da Beneficência nº8, 1050-099, Lisbon, Portugal
- Nova Medical School, Lisbon, Portugal
| | - Aníbal Ferreira
- Nephrology Department, Hospital Curry Cabral | CHULC, Rua da Beneficência nº8, 1050-099, Lisbon, Portugal
- Nova Medical School, Lisbon, Portugal
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Rodrigues FG, Van Der Plas WY, Sotomayor CG, Van Der Vaart A, Kremer D, Pol RA, Kruijff S, Heilberg IP, Bakker SJL, De Borst MH. Pre-Transplant Hyperparathyroidism and Graft or Patient Outcomes After Kidney Transplantation. Transpl Int 2024; 37:11916. [PMID: 38384325 PMCID: PMC10880800 DOI: 10.3389/ti.2024.11916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 01/23/2024] [Indexed: 02/23/2024]
Abstract
The impact of pre-transplant parathyroid hormone (PTH) levels on early or long-term kidney function after kidney transplantation is subject of debate. We assessed whether severe hyperparathyroidism is associated with delayed graft function (DGF), death-censored graft failure (DCGF), or all-cause mortality. In this single-center cohort study, we studied the relationship between PTH and other parameters related to bone and mineral metabolism, including serum alkaline phosphatase (ALP) at time of transplantation with the subsequent risk of DGF, DCGF and all-cause mortality using multivariable logistic and Cox regression analyses. In 1,576 kidney transplant recipients (51.6 ± 14.0 years, 57.3% male), severe hyperparathyroidism characterized by pre-transplant PTH ≥771 pg/mL (>9 times the upper limit) was present in 121 patients. During 5.2 [0.2-30.0] years follow-up, 278 (15.7%) patients developed DGF, 150 (9.9%) DCGF and 432 (28.6%) died. A higher pre-transplant PTH was not associated with DGF (HR 1.06 [0.90-1.25]), DCGF (HR 0.98 [0.87-1.13]), or all-cause mortality (HR 1.02 [0.93-1.11]). Results were consistent in sensitivity analyses. The same applied to other parameters related to bone and mineral metabolism, including ALP. Severe pre-transplant hyperparathyroidism was not associated with an increased risk of DGF, DCGF or all-cause mortality, not supporting the need of correction before kidney transplantation to improve graft or patient survival.
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Affiliation(s)
- Fernanda Guedes Rodrigues
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- Nutrition Post Graduation Program, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Willemijn Y. Van Der Plas
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Camilo German Sotomayor
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Amarens Van Der Vaart
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Daan Kremer
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Robert A. Pol
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Schelto Kruijff
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- Department of Surgery, Martini Hospital Groningen, Groningen, Netherlands
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Ita Pfeferman Heilberg
- Nutrition Post Graduation Program, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
- Nephrology Division, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Stephan J. L. Bakker
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | | | - Martin H. De Borst
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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Jørgensen HS, Evenepoel P. Persistent Hyperparathyroidism: A Reality Calling for Additional Evidence. Am J Kidney Dis 2023; 81:256-258. [PMID: 36424304 DOI: 10.1053/j.ajkd.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/03/2022] [Indexed: 11/23/2022]
Affiliation(s)
- Hanne Skou Jørgensen
- Department of Microbiology, Immunology and Transplantation Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium; Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium; Department of Medicine, Division of Nephrology, University Hospitals Leuven, Leuven, Belgium.
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4
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Persistent hyperparathyroidism in long-term kidney transplantation: time to consider a less aggressive approach. Curr Opin Nephrol Hypertens 2023; 32:20-26. [PMID: 36250468 DOI: 10.1097/mnh.0000000000000840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Persistent hyperparathyroidism affects 50% of long-term kidney transplants with preserved allograft function. Timing, options and the optimal target for treatment remain unclear. Clinical practice guidelines recommend the same therapeutic approach as patients with chronic kidney disease. RECENT FINDINGS Mild to moderate elevation of parathyroid hormone (PTH) levels in long-term kidney transplants may not be associated with bone loss and fracture. Recent findings on bone biopsy revealed the lack of association between hypercalcaemic hyperparathyroidism with pathology of high bone turnover. Elevated PTH levels may be required to maintain normal bone volume. Nevertheless, several large observational studies have revealed the association between hypercalcemia and the elevation of PTH levels with unfavourable allograft and patient outcomes. Both calcimimetics and parathyroidectomy are effective in lowering serum calcium and PTH. A recent meta-analysis suggested parathyroidectomy may be performed safely after kidney transplantation without deterioration of allograft function. SUMMARY Treatment of persistent hyperparathyroidism is warranted in kidney transplants with hypercalcemia and markedly elevated PTH levels. A less aggressive approach should be applied to those with mild to moderate elevation. Whether treatments improve outcomes remain to be elucidated.
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Ferreira AC, Mendes M, Silva C, Cotovio P, Aires I, Navarro D, Caeiro F, Ramos R, Salvador R, Correia B, Cabral G, Nolasco F, Ferreira A. Improvement of Mineral and Bone Disorders After Renal Transplantation. Transplantation 2022; 106:e251-e261. [PMID: 35266925 PMCID: PMC9038238 DOI: 10.1097/tp.0000000000004099] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/07/2022] [Accepted: 01/19/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Posttransplant mineral and bone diseases are causes of fractures, and their association with cardiovascular events is being studied. METHODS We analyzed the evolution of biochemical, histological, and imaging parameters pre- and 1 y post-renal transplantation in 69 patients and correlated mineral and bone findings with coronary calcifications. At inclusion and after 12 mo, clinical data and echocardiographic findings were recorded, and laboratory evaluations, radiography of the pelvis and hands, and bone biopsy were performed. Noncontrast cardiac computed tomography was performed during the second evaluation. RESULTS Serum levels of fibroblast growth factor 23 and sclerostin decreased in all patients, parathyroid hormone levels decreased in 89.8% of patients, bone alkaline phosphatase levels decreased in 68.1% of patients, and alpha-Klotho levels increased in 65.2% of patients. More than half of the patients presented with renal osteodystrophy at both biopsies, but histological findings improved: a significant transition from high to normal or low turnover and no significant differences in volume, mineralization defect, or cortical porosity at the 2 evaluations. Alpha-Klotho, sclerostin, and bone alkaline phosphatase shifts affect bone changes. Neither echocardiographic findings nor vascular calcification scores differed between the 2 points. Both the pretransplant period (dialysis vintage, sclerostin, and low bone volume at baseline) and the maintenance of abnormalities in the posttransplant period (high turnover posttransplant) were the most reliable predictors of the severity of the coronary calcification percentile. CONCLUSIONS Renal transplantation improved bone and mineral abnormalities. The pretransplant period determines the severity of calcification.
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Affiliation(s)
- Ana Carina Ferreira
- Nephrology Department, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
- Nova Medical School, Lisbon, Portugal
| | - Marco Mendes
- Nephrology Department, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Cecília Silva
- Nephrology Department, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Patrícia Cotovio
- Nephrology Department, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Inês Aires
- Nephrology Department, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
- Nova Medical School, Lisbon, Portugal
| | - David Navarro
- Nephrology Department, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Fernando Caeiro
- Nephrology Department, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Rúben Ramos
- Cardiology Department, Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Rute Salvador
- CEDOC, Tissue Repair and Inflammation Lab, Lisbon, Portugal
| | - Bruna Correia
- CEDOC, Tissue Repair and Inflammation Lab, Lisbon, Portugal
| | | | - Fernando Nolasco
- Nephrology Department, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
- Nova Medical School, Lisbon, Portugal
| | - Aníbal Ferreira
- Nephrology Department, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
- Nova Medical School, Lisbon, Portugal
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6
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Keronen S, Martola L, Finne P, Burton IS, Tong XF, Kröger H, Honkanen E. Bone volume, mineral density, and fracture risk after kidney transplantation. PLoS One 2022; 17:e0261686. [PMID: 35349587 PMCID: PMC8963906 DOI: 10.1371/journal.pone.0261686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 12/07/2021] [Indexed: 11/18/2022] Open
Abstract
Background
Disordered mineral metabolism reverses incompletely after kidney transplantation in numerous patients. Post-transplantation bone disease is a combination of pre-existing chronic kidney disease and mineral disorder and often evolving osteoporosis. These two frequently overlapping conditions increase the risk of post-transplantation fractures.
Material and methods
We studied the prevalence of low bone volume in bone biopsies obtained from kidney transplant recipients who were biopsied primarily due to the clinical suspicion of persistent hyperparathyroidism between 2000 and 2015 at the Hospital District of Helsinki and Uusimaa. Parameters of mineral metabolism, results of dual-energy x-ray absorptiometry scans, and the history of fractures were obtained concurrently.
One hundred nine bone biopsies taken at a median of 31 (interquartile range, IQR, 18–70) months after transplantation were included in statistical analysis. Bone turnover was classified as high in 78 (72%) and normal/low in 31 (28%) patients. The prevalence of low bone volume (n = 47, 43%) was higher among patients with low/normal turnover compared to patients with high turnover [18 (58%) vs. 29 (37%), P = 0.05]. Thirty-seven fragility fractures in 23 (21%) transplant recipients corresponding to fracture incidence 15 per 1000 person-years occurred during a median follow-up 9.1 (IQR, 6.3–12.1) years. Trabecular bone volume did not correlate with incident fractures. Accordingly, low bone mineral density at the lumbar spine correlated with low trabecular bone volume, but not with incident fractures. The cumulative corticosteroid dose was an important determinant of low bone volume, but not of incident fractures.
Conclusions
Despite the high prevalence of trabecular bone loss among kidney transplant recipients, the number of fractures was limited. The lack of association between trabecular bone volume and fractures suggests that the bone cortical compartment and quality are important determinants of bone strength and post-transplantation fracture.
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Affiliation(s)
- Satu Keronen
- Department of Nephrology, Abdominal Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- * E-mail:
| | - Leena Martola
- Department of Nephrology, Abdominal Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Patrik Finne
- Department of Nephrology, Abdominal Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Inari S. Burton
- Kuopio Musculoskeletal Research Unit (KMRU), University of Eastern Finland, Kuopio, Finland
| | - Xiaoyu F. Tong
- Kuopio Musculoskeletal Research Unit (KMRU), University of Eastern Finland, Kuopio, Finland
| | - Heikki Kröger
- Kuopio Musculoskeletal Research Unit (KMRU), University of Eastern Finland, Kuopio, Finland
- Department of Orthopedics, Traumatology and Hand Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Eero Honkanen
- Department of Nephrology, Abdominal Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Keronen SM, Martola LAL, Finne P, Burton IS, Tong XF, Kröger HP, Honkanen EO. Clinical Prediction of High-Turnover Bone Disease After Kidney Transplantation. Calcif Tissue Int 2022; 110:324-333. [PMID: 34668028 PMCID: PMC8860959 DOI: 10.1007/s00223-021-00917-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 09/20/2021] [Indexed: 12/04/2022]
Abstract
Bone histomorphometric analysis is the most accurate method for the evaluation of bone turnover, but non-invasive tools are also required. We studied whether bone biomarkers can predict high bone turnover determined by bone histomorphometry after kidney transplantation. We retrospectively evaluated the results of bone biopsy specimens obtained from kidney transplant recipients due to the clinical suspicion of high bone turnover between 2000 and 2015. Bone biomarkers were acquired concurrently. Of 813 kidney transplant recipients, 154 (19%) biopsies were taken at a median of 28 (interquartile range, 18-70) months after engraftment. Of 114 patients included in the statistical analysis, 80 (70%) presented with high bone turnover. Normal or low bone turnover was detected in 34 patients (30%). For discriminating high bone turnover from non-high, alkaline phosphatase, parathyroid hormone, and ionized calcium had the areas under the receiver operating characteristic curve (AUCs) of 0.704, 0.661, and 0.619, respectively. The combination of these markers performed better with an AUC of 0.775. The positive predictive value for high turnover at a predicted probability cutoff of 90% was 95% while the negative predictive value was 35%. This study concurs with previous observations that hyperparathyroidism with or without hypercalcemia does not necessarily imply high bone turnover in kidney transplant recipients. The prediction of high bone turnover can be improved by considering alkaline phosphatase levels, as presented in the logistic regression model. If bone biopsy is not readily available, this model may serve as clinically available tool in recognizing high turnover after engraftment.
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Affiliation(s)
- Satu M Keronen
- Abdominal Center, Department of Nephrology, University of Helsinki and Helsinki University Hospital, (Haartmaninkatu 4), P.O. Box 372, 00029, HUS, Finland.
| | - Leena A L Martola
- Abdominal Center, Department of Nephrology, University of Helsinki and Helsinki University Hospital, (Haartmaninkatu 4), P.O. Box 372, 00029, HUS, Finland
| | - Patrik Finne
- Abdominal Center, Department of Nephrology, University of Helsinki and Helsinki University Hospital, (Haartmaninkatu 4), P.O. Box 372, 00029, HUS, Finland
| | - Inari S Burton
- Kuopio Musculoskeletal Research Unit (KMRU), University of Eastern Finland, P.O.Box 1627, 70211, Kuopio, Finland
| | - Xiaoyu F Tong
- Kuopio Musculoskeletal Research Unit (KMRU), University of Eastern Finland, P.O.Box 1627, 70211, Kuopio, Finland
| | - Heikki P Kröger
- Kuopio Musculoskeletal Research Unit (KMRU), University of Eastern Finland, P.O.Box 1627, 70211, Kuopio, Finland
- Department of Orthopedics, Traumatology, and Hand Surgery, Kuopio University Hospital, P.O.Box 100, 70029, KYS, Finland
| | - Eero O Honkanen
- Abdominal Center, Department of Nephrology, University of Helsinki and Helsinki University Hospital, (Haartmaninkatu 4), P.O. Box 372, 00029, HUS, Finland
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Jung S, Kim H, Kwon H, Shin S, Kim YH, Kim WW, Sung TY, Lee YM, Chung KW, Park SK, Baek CH. Parathyroidectomy versus cinacalcet in the treatment of tertiary hyperparathyroidism after kidney transplantation: a retrospective study. Kidney Res Clin Pract 2022; 41:473-481. [PMID: 35286788 PMCID: PMC9346402 DOI: 10.23876/j.krcp.21.210] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 12/10/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Suyun Jung
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyosang Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyunwook Kwon
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung Shin
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young Hoon Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Won Woong Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Tae-Yon Sung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yu-Mi Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ki-Wook Chung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Su-Kil Park
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chung Hee Baek
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Abreu ALCS, Soeiro EMD, Bedram LG, de Andrade MC, Lopes R. Brazilian guidelines for chronic kidney disease-mineral and bone metabolism disorders in children and adolescents. J Bras Nefrol 2021; 43:680-692. [PMID: 34910806 PMCID: PMC8823923 DOI: 10.1590/2175-8239-jbn-2021-s114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 07/09/2021] [Indexed: 11/22/2022] Open
Affiliation(s)
| | - Emília Maria Dantas Soeiro
- Universidade Federal de Pernambuco, Recife, PE, Brazil
- Instituto de Medicina Integral Professor Fernando Figueira - IMIP,
Recife, PE, Brazil
| | | | | | - Renata Lopes
- Universidade Federal de São Paulo, São Paulo, SP, Brazil
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Jørgensen HS, Behets G, Bammens B, Claes K, Meijers B, Naesens M, Sprangers B, Kuypers DRJ, D'Haese P, Evenepoel P. Patterns of renal osteodystrophy one year after kidney transplantation. Nephrol Dial Transplant 2021; 36:2130-2139. [PMID: 34383929 DOI: 10.1093/ndt/gfab239] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Renal osteodystrophy is considered common, but is not well characterized, in contemporary kidney transplant recipients. This study reports extensively on bone phenotype by bone histomorphometry, bone densitometry, and novel bone biomarkers 1 year after kidney transplantation. METHODS A transiliac bone biopsy and dual energy x-ray absorptiometry were performed in 141 unselected kidney transplant recipients in this observational cohort study. Blood and 24 hr urine samples were collected simultaneously. RESULTS Median age was 57 ± 11 years, 71% were men, and all were of Caucasian ethnicity. Bone turnover was normal in 71% of patients, low in 26%, and high in just four cases (3%). Hyperparathyroidism with hypercalcemia was present in 13% of patients, of which one had high bone turnover. Delayed bone mineralization was detected in 16% of patients, who were characterized by hyperparathyroidism (137 vs. 53 ρg/mL), a higher fractional excretion of phosphate (40 vs. 32%), and lower levels of phosphate (2.68 vs 3.18 mg/dL) and calcidiol (29 vs. 37 ng/mL) compared to patients with normal bone mineralization. Osteoporosis was present in 15-46% of patients, with the highest prevalence at the distal skeleton. The proportion of osteoporotic patients was comparable across categories of bone turnover and mineralization. CONCLUSION The majority of kidney transplant recipients, including patients with osteoporosis, have a normal bone turnover at 1-year post-transplant. Low bone turnover is seen in a substantial subset, while high bone turnover is rare. Vitamin D deficiency and hypophosphatemia represent potential interventional targets to improve bone health post-transplant.
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Affiliation(s)
- Hanne Skou Jørgensen
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Kidney Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Geert Behets
- Laboratory of Pathophysiology, University of Antwerp, Wilrijk, Belgium
| | - Bert Bammens
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
| | - Kathleen Claes
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
| | - Bjorn Meijers
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
| | - Ben Sprangers
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
| | - Dirk R J Kuypers
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
| | - Patrick D'Haese
- Laboratory of Pathophysiology, University of Antwerp, Wilrijk, Belgium
| | - Pieter Evenepoel
- Department of Microbiology, Immunology and Transplantation; Nephrology and Renal Transplantation Research Group, KU, Leuven, Belgium.,Department of Medicine, Division of Nephrology, University Hospitals Leuven, Belgium
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11
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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: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [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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12
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Ferreira AC, Mendes M, Silva C, Cotovio P, Aires I, Navarro D, Caeiro F, Salvador R, Correia B, Cabral G, Nolasco F, Ferreira A. Bone densitometry versus bone histomorphometry in renal transplanted patients: a cross-sectional study. Transpl Int 2021; 34:1065-1073. [PMID: 33909300 DOI: 10.1111/tri.13888] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/23/2021] [Accepted: 04/14/2021] [Indexed: 11/28/2022]
Abstract
Bone loss leads to increase risk of fractures in renal transplantation. The aim of this study was to analyse the relationship between bone densitometry (DXA) findings, bone histomorphometry and bone-related molecules 1-year after renal transplantation. We performed a cross-sectional study of de novo renal transplanted patients that agreed to perform a bone biopsy and a DXA examination 1 year after transplantation. All patients underwent a laboratory evaluation, bone biopsy, DXA examination and cardiac CT 1 year after transplantation. 67 patients were included, 16 had a normal examination, and 18 patients were classified as having osteoporosis by DXA. Correlations between bone mineral density and T-scores of total femur and femoral neck were the ones that best correlated with bone volume assessed by a bone biopsy. The sensitivity of DXA for osteoporosis diagnosis was 47.0%, and the specificity was 81.2%. The positive predictive value was 50.0%, and the negative predictive value (NPV) was 80.0%. DXA parameters also correlated with klotho and sclerostin serum levels. In this population, a normal examination excluded the presence of osteoporosis, helping in identifying patients that would not benefit from therapy. Overall, densitometry in total femur and femoral neck correlated well with bone volume measured by bone biopsy.
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Affiliation(s)
- Ana Carina Ferreira
- Nephrology Department, Hospital Curry Cabral, CHULC, Lisbon, Portugal.,Nova Medical School, Lisbon, Portugal
| | - Marco Mendes
- Nephrology Department, Hospital Curry Cabral, CHULC, Lisbon, Portugal
| | - Cecília Silva
- Nephrology Department, Hospital Curry Cabral, CHULC, Lisbon, Portugal
| | - Patrícia Cotovio
- Nephrology Department, Hospital Curry Cabral, CHULC, Lisbon, Portugal
| | - Inês Aires
- Nephrology Department, Hospital Curry Cabral, CHULC, Lisbon, Portugal.,Nova Medical School, Lisbon, Portugal
| | - David Navarro
- Nephrology Department, Hospital Curry Cabral, CHULC, Lisbon, Portugal
| | - Fernando Caeiro
- Nephrology Department, Hospital Curry Cabral, CHULC, Lisbon, Portugal
| | - Rute Salvador
- Tissue Repair and Inflammation Lab, CEDOC, Lisbon, Portugal
| | - Bruna Correia
- Tissue Repair and Inflammation Lab, CEDOC, Lisbon, Portugal
| | | | - Fernando Nolasco
- Nephrology Department, Hospital Curry Cabral, CHULC, Lisbon, Portugal.,Nova Medical School, Lisbon, Portugal
| | - Aníbal Ferreira
- Nephrology Department, Hospital Curry Cabral, CHULC, Lisbon, Portugal.,Nova Medical School, Lisbon, Portugal
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13
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Haffner D, Leifheit-Nestler M. CKD-MBD post kidney transplantation. Pediatr Nephrol 2021; 36:41-50. [PMID: 31858226 DOI: 10.1007/s00467-019-04421-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 10/28/2019] [Accepted: 11/12/2019] [Indexed: 12/22/2022]
Abstract
Complications of chronic kidney disease-associated mineral and bone disorders (CKD-MBD) are frequently observed in pediatric kidney transplant recipients and are associated with high morbidity, including growth failure, leg deformities, bone pain, fractures, osteonecrosis, and vascular calcification. Post-transplant CKD-MBD is mainly due to preexisting renal osteodystrophy and cardiovascular changes at the time of transplantation, glucocorticoid treatment, and reduced graft function. In addition, persistent elevated levels of parathyroid hormone (PTH) and fibroblast growth factor 23 may cause hypophosphatemia, resulting in impaired bone mineralization. Patient monitoring should include assessment of growth, leg deformities, and serum levels of calcium, phosphate, magnesium, alkaline phosphatase, 25-hydroxyvitamin D, and PTH. Therapy should primarily focus on regular physical activity, preservation of transplant function, and steroid-sparing immunosuppressive protocols. In addition, adequate monitoring and treatment of vitamin D and mineral metabolism including vitamin D supplementation, oral phosphate, and/or magnesium supplementation, in case of persistent hypophosphatemia/hypomagnesemia, and treatment with active vitamin D in cases of persistent secondary hyperparathyroidism. The latter should be done using the minimum PTH-suppressive dosages aiming at the recommended CKD stage-dependent PTH target range. Finally, treatment with recombinant human growth hormone should be considered in patients lacking catch-up growth within the first year after transplantation.
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Affiliation(s)
- Dieter Haffner
- Department of Paediatric Kidney, Liver and Metabolic Diseases, Paediatric Research Center, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Maren Leifheit-Nestler
- Department of Paediatric Kidney, Liver and Metabolic Diseases, Paediatric Research Center, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.,Paediatric Research Center, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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14
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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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15
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Capelli I, Cianciolo G, Gasperoni L, Galassi A, Ciceri P, Cozzolino M. Nutritional vitamin D in CKD: Should we measure? Should we treat? Clin Chim Acta 2019; 501:186-197. [PMID: 31770508 DOI: 10.1016/j.cca.2019.11.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 11/04/2019] [Accepted: 11/06/2019] [Indexed: 02/08/2023]
Abstract
Vitamin Ddeficiency is frequently present in patients affected by chronic kidney disease (CKD). Experimental studies demonstrated that Vitamin D may play a role in the pathophysiology of diseases beyond mineral bone disorders in CKD (CKD-MBD). Unfortunately, the lack of large and interventional studies focused on the so called "non-classic" effects of 25(OH) Vitamin D supplementation in CKD patients, doesn't permit to conclude definitely about the beneficial effects of this supplementation in clinical practice. In conclusion, treatment of nutritional vitamin D deficiency in CKD may play a central role in both bone homeostasis and cardiovascular outcomes, but there is not clear evidence to support one formulation of nutritional vitamin D over another in CKD.
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Affiliation(s)
- Irene Capelli
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Giuseppe Cianciolo
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Lorenzo Gasperoni
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Andrea Galassi
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Italy
| | - Paola Ciceri
- Renal Research Laboratory, Department of Nephrology, Dialysis and Renal Transplant, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Mario Cozzolino
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Italy.
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16
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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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17
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Keronen S, Martola L, Finne P, Burton IS, Kröger H, Honkanen E. Changes in Bone Histomorphometry after Kidney Transplantation. Clin J Am Soc Nephrol 2019; 14:894-903. [PMID: 31088851 PMCID: PMC6556726 DOI: 10.2215/cjn.09950818] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Accepted: 04/02/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Over the past decade, the management of CKD-mineral and bone disorder has changed substantially, altering the pattern of bone disease in CKD. We aimed to evaluate the natural history of kidney bone disease in contemporary kidney transplant recipients and patients on dialysis. DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS Sixty one patients on dialysis who were referred to kidney transplantation participated in this prospective cohort study during November 2009 and December 2010. We performed baseline bone biopsies while the patients were on dialysis and repeated the procedure in 56 patients at 2 years after kidney transplantation or 2 years after baseline if transplantation was not performed. Measurements of mineral metabolism and bone turnover, as well as dual energy x-ray absorptiometry scans, were obtained concurrently. RESULTS A total of 37 out of 56 participants received a kidney transplant, of which 27 underwent successful repeat bone biopsy. The proportion of patients with high bone turnover declined from 63% at baseline to 19% at 2 years after kidney transplantation, whereas the proportion of those with low bone turnover increased from 26% to 52%. Of 19 participants remaining on dialysis after 2 years, 13 underwent successful repeat biopsy. The proportion of patients remaining on dialysis with high bone turnover decreased from 69% to 31%, and low bone turnover increased from 8% to 38%. Abnormal bone mineralization increased in transplant recipients from 33% to 44%, but decreased in patients remaining on dialysis from 46% to 15%. Trabecular bone volume showed little change after transplantation, but low bone volume increased in patients remaining on dialysis. Bone mineral density did not correlate with histomorphometric findings. CONCLUSIONS Bone turnover decreased over time both in patients remaining on dialysis and in kidney transplant recipients. Bone mineral density and bone biomarkers were not associated with bone metabolism changes detected in bone biopsy specimens.
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Affiliation(s)
- Satu Keronen
- Abdominal Center, Department of Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland;
| | - Leena Martola
- Abdominal Center, Department of Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Patrik Finne
- Abdominal Center, Department of Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Inari S Burton
- Kuopio Musculoskeletal Research Unit, University of Eastern Finland, Kuopio, Finland; and
| | - Heikki Kröger
- Kuopio Musculoskeletal Research Unit, University of Eastern Finland, Kuopio, Finland; and.,Department of Orthopedics, Traumatology and Hand Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Eero Honkanen
- Abdominal Center, Department of Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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18
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Abstract
PURPOSE OF REVIEW Despite metabolic improvements following kidney transplantation, transplant recipients still often suffer from complex mineral and bone disease after transplantation. RECENT FINDINGS The pathophysiology of post-transplant disease is unique, secondary to underlying pre-transplant mineral and bone disease, immunosuppression, and changing kidney function. Changes in modern immunosuppression regimens continue to alter the clinical picture. Modern management includes reducing cumulative steroid exposure and correcting the biochemical abnormalities in mineral metabolism. While bone mineral density screening appears to help predict fracture risk and anti-osteoporotic therapy appears to have a positive effect on bone mineral density, more data regarding specific treatment is necessary. Patients with mineral and bone disease after kidney transplantation require special care in order to properly manage and mitigate their mineral and bone disease. Recent changes in clinical management of transplant patients may also be changing the implications on patients' mineral and bone disease.
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Affiliation(s)
- Ariella M Altman
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Stuart M Sprague
- Division of Nephrology and Hypertension, NorthShore University HealthSystem, University of Chicago Medical School, 2650 Ridge Avenue, Evanston, IL, 60201, USA.
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19
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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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20
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Glendenning P, Chubb SP, Vasikaran S. Clinical utility of bone turnover markers in the management of common metabolic bone diseases in adults. Clin Chim Acta 2018; 481:161-170. [DOI: 10.1016/j.cca.2018.03.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 03/08/2018] [Accepted: 03/10/2018] [Indexed: 10/17/2022]
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21
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Evenepoel P, D'Haese P, Bacchetta J, Cannata-Andia J, Ferreira A, Haarhaus M, Mazzaferro S, Lafage Proust MH, Salam S, Spasovski G, Cozzolino M. Bone biopsy practice patterns across Europe: the European renal osteodystrophy initiative-a position paper. Nephrol Dial Transplant 2018; 32:1608-1613. [PMID: 28339949 DOI: 10.1093/ndt/gfw468] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Accepted: 12/20/2016] [Indexed: 02/04/2023] Open
Abstract
Renal osteodystrophy (ROD) is a heterogeneous group of metabolic bone diseases complicating progressive chronic kidney disease (CKD). Bone biomarkers and bone imaging techniques may help to assess bone health and predict fractures in CKD but do have important inherent limitations. By informing on bone turnover and mineralization, a bone biopsy may help to guide prevention and treatment of ROD and its consequences. According to a recent survey conducted among European nephrologists, bone biopsies are performed rather exceptionally, both for clinical and research purposes. Obviously, clinical research in the field of ROD is threatened by vanishing clinical and pathological expertise, small patient cohorts and scientific isolation. In March 2016, the European Renal Osteodystrophy (EU-ROD) initiative was created under the umbrella of the ERA-EDTA CKD-mineral and bone disorder (MBD) Working Group to revitalize bone biopsy as a clinically useful tool in the diagnostic workup of CKD-MBD and to foster research on the epidemiology, implications and reversibility of ROD. As such, the EU-ROD initiative aims to increase the understanding of ROD and ultimately to improve outcomes in CKD patients.
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Affiliation(s)
- Pieter Evenepoel
- Department of Immunology and Microbiology, Laboratory of Nephrology, KU Leuven - University of Leuven and Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Belgium
| | - Patrick D'Haese
- Department of Biomedical Sciences, Laboratory of Pathophysiology, Antwerp University, Wilrijk, Belgium
| | - Justine Bacchetta
- Centre de Référence des Maladies Rénales Rares, Hôpital Femme Mère Enfant, Bron, France
| | - Jorge Cannata-Andia
- Hospital Universitario Central de Asturias, Oviedo University REDinREN IIS Carlos III, Bone and Mineral Research Unit, Oviedo, Spain
| | - Anibal Ferreira
- Nova Medical School - Faculdade de Ciências Médicas da Universidade Nova de Lisboa e Centro Hospitalar Lisboa Central - Hospital de Curry Cabral, Lisboa, Portugal
| | - Mathias Haarhaus
- Department of Clinical Science, Intervention and Technology, Division of Renal Medicine, Karolinska Institutet and Department of Nephrology, Karolinska University Hospital, Stockholm, Sweden
| | - Sandro Mazzaferro
- Department of Cardiovascular, Respiratory, Nephrologic and Geriatric Sciences, Sapienza University, Rome, Italy
| | | | - Syazrah Salam
- Sheffield Kidney Institute and Academic Unit of Bone Metabolism, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Goce Spasovski
- Department of Nephrology, Medical Faculty, University of Skopje, Macedonia
| | - Mario Cozzolino
- Department of Health Sciences, Renal Division, San Paolo Hospital, University of Milan, Milan, Italy
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22
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Diamond T, Elder GJ. Is there a practical role for bone biopsy in chronic kidney disease? Nephrology (Carlton) 2018; 22 Suppl 2:22-26. [PMID: 28429554 DOI: 10.1111/nep.13017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Bone biopsy is currently the only means to accurately assess renal osteodystrophy and responses to therapeutic interventions. With sedation, the technique is relatively painless, and complications are uncommon. Bone biopsy should be considered when the aetiology of symptoms or biochemical abnormalities is in question, and results may lead to changes in therapy. Although it remains prudent to use antiresorptive drugs cautiously in patients with chronic kidney disease (CKD) stages 3a-4 and low bone mineral density, bone biopsy may not be warranted before commencing therapy in these patients. Histomorphometric indices adopted for bone biopsy assessment are turnover (T), mineralisation (M) and volume (V). Often, only measurements of trabecular bone are reported; however, marked cortical changes are common in CKD and may be critical to bone structure and integrity. MicroCT of bone biopsies can rapidly assess static parameters and provides information on the cortical and trabecular compartments that may influence management. Limitations of bone biopsy include the time required for pre-biopsy tetracycline labelling and sample processing, and a paucity of facilities to process and report samples. Patients with CKD may not respond predictably to treatments, and because the biopsy sample is illustrative of activity at only one skeletal site and one point in time, assessment of real-time laboratory trends is always required. Optimally, we need a non-invasive 'virtual bone biopsy' that provides information for initiating and monitoring therapy. However, bone biopsy is the current standard by which the accuracy of investigational imaging techniques, hormonal values and biochemical turnover markers are judged.
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Affiliation(s)
- Terrence Diamond
- Department of Endocrinology, St George Hospital, University of NSW, Sydney, Australia
| | - Grahame J Elder
- Department of Renal Medicine, Westmead Hospital, Westmead, Australia.,Osteoporosis and Bone Biology Division, Garvan Institute for Medical Research, Darlinghurst, Australia
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23
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Baker RJ, Mark PB, Patel RK, Stevens KK, Palmer N. Renal association clinical practice guideline in post-operative care in the kidney transplant recipient. BMC Nephrol 2017; 18:174. [PMID: 28571571 PMCID: PMC5455080 DOI: 10.1186/s12882-017-0553-2] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 04/16/2017] [Indexed: 02/08/2023] Open
Abstract
These guidelines cover the care of patients from the period following kidney transplantation until the transplant is no longer working or the patient dies. During the early phase prevention of acute rejection and infection are the priority. After around 3-6 months, the priorities change to preservation of transplant function and avoiding the long-term complications of immunosuppressive medication (the medication used to suppress the immune system to prevent rejection). The topics discussed include organization of outpatient follow up, immunosuppressive medication, treatment of acute and chronic rejection, and prevention of complications. The potential complications discussed include heart disease, infection, cancer, bone disease and blood disorders. There is also a section on contraception and reproductive issues.Immediately after the introduction there is a statement of all the recommendations. These recommendations are written in a language that we think should be understandable by many patients, relatives, carers and other interested people. Consequently we have not reworded or restated them in this lay summary. They are graded 1 or 2 depending on the strength of the recommendation by the authors, and AD depending on the quality of the evidence that the recommendation is based on.
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Affiliation(s)
- Richard J Baker
- Renal Unit, St. James's University Hospital, Leeds, England.
| | - Patrick B Mark
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, Scotland
| | - Rajan K Patel
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, Scotland
| | - Kate K Stevens
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, Scotland
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24
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Retrospective Study Looking at Cinacalcet in the Management of Hyperparathyroidism after Kidney Transplantation. J Transplant 2017; 2017:8720283. [PMID: 28386475 PMCID: PMC5366779 DOI: 10.1155/2017/8720283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 02/26/2017] [Indexed: 11/17/2022] Open
Abstract
Objectives. The primary objective of this study is to evaluate the use of cinacalcet in the management of hyperparathyroidism in kidney transplant recipients. The secondary objective is to identify baseline factors that predict cinacalcet use after transplantation. Methods. In this single-center retrospective study, we conducted a chart review of all patients having been transplanted from 2003 to 2012 and having received cinacalcet up to kidney transplantation and/or thereafter. Results. Twenty-seven patients were included with a mean follow-up of 2.9 ± 2.4 years. Twenty-one were already taking cinacalcet at the time of transplantation. Cinacalcet was stopped within the first month in 12 of these patients of which 7 had to restart therapy. The main reason for restarting cinacalcet was hypercalcemia. Length of treatment was 23 ± 26 months. There were only 3 cases of mild hypocalcemia. There was no statistically significant association between baseline factors and cinacalcet status a year later. Conclusions. Discontinuing cinacalcet within the first month of kidney transplantation often leads to hypercalcemia. Cinacalcet appears to be an effective treatment of hypercalcemic hyperparathyroidism in kidney transplant recipients. Further studies are needed to evaluate safety and long-term benefits.
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25
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Evenepoel P, Behets GJ, Viaene L, D'Haese PC. Bone histomorphometry in de novo renal transplant recipients indicates a further decline in bone resorption 1 year posttransplantation. Kidney Int 2017; 91:469-476. [DOI: 10.1016/j.kint.2016.10.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 09/29/2016] [Accepted: 10/06/2016] [Indexed: 10/20/2022]
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26
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Carvalho C, Magalhães J, Pereira L, Simões-Silva L, Castro-Ferreira I, Frazão JM. Evolution of bone disease after kidney transplantation: A prospective histomorphometric analysis of trabecular and cortical bone. Nephrology (Carlton) 2016. [PMID: 26201946 DOI: 10.1111/nep.12570] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM Post-transplant bone disease results from multiple factors, including previous bone and mineral metabolism disturbances and effects from transplant-related medications. Bone biopsy remains the gold-standard diagnostic tool. METHODS We aimed to prospectively evaluate trabecular and cortical bone by histomorphometry after kidney transplantation. Seven patients, willing to perform follow-up bone biopsy, were included in the study. Dual-X-ray absorptiometry and trans-iliac bone biopsy were performed within the first 2 months after renal transplantation and repeated after 2-5 years of follow-up. RESULTS Follow-up biopsy revealed a significant decrease in osteoblast surface/bone surface (0.91 ± 0.81 to 0.47 ± 0.12%, P = 0.036), osteoblasts number/bone surface (0.45 (0.23, 0.94) to 0.00/mm(2) , P = 0.018) and erosion surface/bone surface (3.75 ± 2.02 to 2.22 ± 1.38%, P = 0.044). A decrease in trabecular number (3.55 (1.81, 2.89) to 1.55/mm (1.24, 2.06), P = 0.018) and increase in trabecular separation (351.65 ± 135.04 to 541.79 ± 151.91 μm, P = 0.024) in follow-up biopsy suggest loss in bone quantity. We found no significant differences in cortical analysis, except a reduction in external cortical osteonal eroded surface (5.76 (2.94, 13.97) to 3.29% (0.00, 6.67), P = 0.043). Correlations between bone histomorphometric and dual-X-ray absorptiometry parameters gave inconsistent results. CONCLUSIONS The results show a reduction in bone activity, suggesting increased risk of adynamic bone and loss of bone volume. Cortical bone seems less affected by post-transplant biological changes in the first years after kidney transplantation.
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Affiliation(s)
- Catarina Carvalho
- Nephrology and Infectiology Research and Development Group, INEB, Porto, Portugal
| | - Juliana Magalhães
- Nephrology and Infectiology Research and Development Group, INEB, Porto, Portugal
| | - Luciano Pereira
- Nephrology and Infectiology Research and Development Group, INEB, Porto, Portugal
| | - Liliana Simões-Silva
- Nephrology Research and Development Unit, Medical School, Porto University, Porto, Portugal
| | - Inês Castro-Ferreira
- Nephrology Research and Development Unit, Medical School, Porto University, Porto, Portugal
| | - João Miguel Frazão
- Nephrology and Infectiology Research and Development Group, INEB, Porto, Portugal
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El-khatib MM, El-Shahaby AR, EEl-Khashab SO, El. Mohamed E, Shaker AM. Fibroblast growth factor 23 levels before and after renal transplantation. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2016. [DOI: 10.4103/1110-7782.193887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Bonani M, Frey D, Brockmann J, Fehr T, Mueller TF, Saleh L, von Eckardstein A, Graf N, Wüthrich RP. Effect of Twice-Yearly Denosumab on Prevention of Bone Mineral Density Loss in De Novo Kidney Transplant Recipients: A Randomized Controlled Trial. Am J Transplant 2016; 16:1882-91. [PMID: 26713403 DOI: 10.1111/ajt.13692] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 12/16/2015] [Accepted: 12/17/2015] [Indexed: 01/25/2023]
Abstract
We conducted an open-label, prospective, randomized trial to assess the efficacy and safety of RANKL inhibition with denosumab to prevent the loss of bone mineral density (BMD) in the first year after kidney transplantation. Ninety kidney transplant recipients were randomized 1:1 2 weeks after surgery to receive denosumab (60 mg at baseline and 6 months) or no treatment. After 12 months, total lumbar spine areal BMD (aBMD) increased by 4.6% (95% confidence interval [CI] 3.3-5.9%) in 46 patients in the denosumab group and decreased by -0.5% (95% CI -1.8% to 0.9%) in 44 patients in the control group (between-group difference 5.1% [95% CI 3.1-7.0%], p < 0.0001). Denosumab also increased aBMD at the total hip by 1.9% (95% CI, 0.1-3.7%; p = 0.035) over that in the control group at 12 months. High-resolution peripheral quantitative computed tomography in a subgroup of 24 patients showed that denosumab increased volumetric BMD at the distal tibia and radius (all p < 0.05). Biomarkers of bone turnover (C-terminal telopeptide of type I collagen, procollagen type I N-terminal propeptide) markedly decreased with denosumab (all p < 0.0001). Episodes of cystitis and asymptomatic hypocalcemia occurred more often with denosumab, whereas graft function, rate of rejections, and incidence of opportunistic infections were similar. In conclusion, denosumab increased BMD in the first year after kidney transplantation but was associated with more frequent episodes of urinary tract infection.
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Affiliation(s)
- M Bonani
- Division of Nephrology, University Hospital Zürich and University of Zürich, Zürich, Switzerland
| | - D Frey
- Division of Rheumatology, University Hospital Zürich and University of Zürich, Zürich, Switzerland
| | - J Brockmann
- Division of Visceral and Transplantation Surgery, University Hospital Zürich and University of Zürich, Zürich, Switzerland
| | - T Fehr
- Division of Nephrology, University Hospital Zürich and University of Zürich, Zürich, Switzerland
| | - T F Mueller
- Division of Nephrology, University Hospital Zürich and University of Zürich, Zürich, Switzerland
| | - L Saleh
- Institute of Clinical Chemistry, University Hospital Zürich and University of Zürich, Zürich, Switzerland
| | - A von Eckardstein
- Institute of Clinical Chemistry, University Hospital Zürich and University of Zürich, Zürich, Switzerland
| | - N Graf
- Graf Biostatistics, Winterthur, Switzerland
| | - R P Wüthrich
- Division of Nephrology, University Hospital Zürich and University of Zürich, Zürich, Switzerland
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Morrone LF, Bolasco P, Camerini C, Cianciolo G, Cupisti A, Galassi A, Mazzaferro S, Russo D, Russo L, Cozzolino M. Vitamin D in patients with chronic kidney disease: a position statement of the Working Group "Trace Elements and Mineral Metabolism" of the Italian Society of Nephrology. J Nephrol 2016; 29:305-328. [PMID: 27062486 DOI: 10.1007/s40620-016-0305-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 03/30/2016] [Indexed: 02/07/2023]
Abstract
In the late 1970s, calcitriol was introduced into clinical practice for the management of secondary renal hyperparathyroidism in chronic kidney disease (CKD). Since then, the use of calcifediol or other native forms of vitamin D was largely ignored until the publication of the 2009 Kidney Disease Improving Global Outcomes (KDIGO) recommendations. The guidelines suggested that measurement of circulating levels of 25(OH)D (calcifediol) and its supplementation were to be performed on the same basis as for the general population. This indication was based on the fact that the precursors of active vitamin D had provided to CKD patients considerable benefits in survival, mainly due to their pleiotropic effects on the cardiovascular system. However, despite the long-term use of various classes of vitamin D in CKD, a clear definition is still lacking concerning the most appropriate time for initiation of therapy, the best compound to prescribe (active metabolites or analogs), the proper dosage, and the most suitable duration of therapy. The aim of this position statement is to provide and critically appraise the current plentiful evidence on vitamin D in different clinical settings related to CKD, particularly focusing on outcomes, monitoring and treatment-associated risks. However, it should be taken in account that position statements are meant to provide guidance; therefore, they are not to be considered prescriptive for all patients and, importantly, they cannot replace the judgment of clinicians.
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Affiliation(s)
- Luigi Francesco Morrone
- Nephrology, Dialysis and Renal Transplantation Unit, University Hospital "Policlinico", Bari, Italy.
| | - Pergiorgio Bolasco
- Territorial Unit of Nephrology and Dialysis-ASL 8 of Cagliari, Cagliari, Italy
| | - Corrado Camerini
- Operative Unit of Nephrology, AO Spedali Civili di Brescia and University of Brescia, Brescia, Italy
| | - Giuseppe Cianciolo
- Nephrology Dialysis and Renal Transplantation Unit, S. Orsola University Hospital, Bologna, Italy
| | - Adamasco Cupisti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Sandro Mazzaferro
- Department of Cardiovascular Respiratory Nephrologic Anesthetic and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Domenico Russo
- Department of Public Health, Unit of Nephrology and Hypertension, University of Naples Federico II, Naples, Italy
| | - Luigi Russo
- Department of Public Health, Unit of Nephrology and Hypertension, University of Naples Federico II, Naples, Italy
| | - Mario Cozzolino
- Renal Division and Laboratory of Experimental Nephrology, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy
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Cruzado JM, Moreno P, Torregrosa JV, Taco O, Mast R, Gómez-Vaquero C, Polo C, Revuelta I, Francos J, Torras J, García-Barrasa A, Bestard O, Grinyó JM. A Randomized Study Comparing Parathyroidectomy with Cinacalcet for Treating Hypercalcemia in Kidney Allograft Recipients with Hyperparathyroidism. J Am Soc Nephrol 2015; 27:2487-94. [PMID: 26647424 DOI: 10.1681/asn.2015060622] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Accepted: 11/01/2015] [Indexed: 12/16/2022] Open
Abstract
Tertiary hyperparathyroidism is a common cause of hypercalcemia after kidney transplant. We designed this 12-month, prospective, multicenter, open-label, randomized study to evaluate whether subtotal parathyroidectomy is more effective than cinacalcet for controlling hypercalcemia caused by persistent hyperparathyroidism after kidney transplant. Kidney allograft recipients with hypercalcemia and elevated intact parathyroid hormone (iPTH) concentration were eligible if they had received a transplant ≥6 months before the study and had an eGFR>30 ml/min per 1.73 m(2) The primary end point was the proportion of patients with normocalcemia at 12 months. Secondary end points were serum iPTH concentration, serum phosphate concentration, bone mineral density, vascular calcification, renal function, patient and graft survival, and economic cost. In total, 30 patients were randomized to receive cinacalcet (n=15) or subtotal parathyroidectomy (n=15). At 12 months, ten of 15 patients in the cinacalcet group and 15 of 15 patients in the parathyroidectomy group (P=0.04) achieved normocalcemia. Normalization of serum phosphate concentration occurred in almost all patients. Subtotal parathyroidectomy induced greater reduction of iPTH and associated with a significant increase in femoral neck bone mineral density; vascular calcification remained unchanged in both groups. The most frequent adverse events were digestive intolerance in the cinacalcet group and hypocalcemia in the parathyroidectomy group. Surgery would be more cost effective than cinacalcet if cinacalcet duration reached 14 months. All patients were alive with a functioning graft at the end of follow-up. In conclusion, subtotal parathyroidectomy was superior to cinacalcet in controlling hypercalcemia in these patients with kidney transplants and persistent hyperparathyroidism.
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Affiliation(s)
- Josep M Cruzado
- Nephrology Department, Hospital Universitari de Bellvitge, University of Barcelona, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain;
| | | | - José V Torregrosa
- Nephrology and Renal Transplant Service, Hospital Clínic, Barcelona, Spain
| | - Omar Taco
- Nephrology Department, Hospital Universitari de Bellvitge, University of Barcelona, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Carmen Gómez-Vaquero
- Rheumatology, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; and
| | - Carolina Polo
- Nephrology Department, Hospital Universitari de Bellvitge, University of Barcelona, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Ignacio Revuelta
- Nephrology and Renal Transplant Service, Hospital Clínic, Barcelona, Spain
| | | | - Joan Torras
- Nephrology Department, Hospital Universitari de Bellvitge, University of Barcelona, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Oriol Bestard
- Nephrology Department, Hospital Universitari de Bellvitge, University of Barcelona, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Josep M Grinyó
- Nephrology Department, Hospital Universitari de Bellvitge, University of Barcelona, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
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Abstract
PURPOSE OF REVIEW Mineral and bone disorders are common problems in organ transplant recipients. Successful transplantation solves many aspects of abnormal mineral and bone metabolism, but the degree of improvement is frequently incomplete. Posttransplant bone disease can affect long-term outcomes as well as increase the likelihood of fracture. In this article, we reviewed the major posttransplant bone diseases and recent advances in treatment strategies. RECENT FINDINGS Pretransplant bone disease and immunosuppressants are important risk factors for posttransplant bone disease. Corticosteroid withdrawal may result in minimal or no protection against fractures, with increased risk for acute rejection. Vitamin D analogue and bisphosphonate are frequently used to prevent and treat posttransplant osteoporosis. Posttransplant hyperparathyroidism increases the risk for all-cause mortality and graft loss, but not major cardiovascular events. Cinacalcet was well tolerated and effectively controlled hypercalcemic hyperparathyroidism; however, it did not improve bone mineral density and discontinuation led to parathyroid hormone rebound. Six-month paricalcitol supplementation reduced parathyroid hormone levels and attenuated bone remodeling and mineral loss in case of posttransplant hyperparathyroidism. SUMMARY Posttransplant bone diseases present in various forms, including osteoporosis, hyperparathyroidism, adynamic bone disease, and osteonecrosis. Prophylactic and therapeutic approaches to both pretransplant and posttransplant periods should be considered.
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Affiliation(s)
- Hee Jung Jeon
- aDepartment of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, Republic of Korea bDivision of Nephrology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea cTransplantation Center, Seoul National University Hospital, Seoul, Republic of Korea *Hee Jung Jeon and Hyosang Kim contributed equally to the writing of this article
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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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Long-term clinical practice experience with cinacalcet for treatment of hypercalcemic hyperparathyroidism after kidney transplantation. BIOMED RESEARCH INTERNATIONAL 2015; 2015:292654. [PMID: 25861621 PMCID: PMC4377458 DOI: 10.1155/2015/292654] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 02/09/2015] [Indexed: 12/11/2022]
Abstract
Within this prospective, open-label, self-controlled study, we evaluated the long-term effects of the calcimimetic cinacalcet on calcium and phosphate homeostasis in 44 kidney transplant recipients (KTRs) with hypercalcemic hyperparathyroidism by comparing biochemical parameters of mineral metabolism between pre- and posttreatment periods. Results are described as mean differences (95% CIs) between pre- and posttreatment medians that summarize all repeated measurements of a parameter of interest between the date of initial hypercalcemia and cinacalcet initiation (median of 1.6 (IQR: 0.6-3.8) years) and up to four years after treatment start, respectively. Cinacalcet was initiated after 1.8 (0.8-4.7) years posttransplant and maintained for 6.2 (3.9-7.6) years. It significantly decreased total serum calcium (-0.30 (-0.34 to -0.26) mmol/L, P < 0.001) and parathyroid hormone levels (-79 (-103 to -55) pg/mL, P < 0.001). Serum levels of inorganic phosphate (Pi) and renal tubular reabsorption of phosphate to glomerular filtration rate (TmP/GFR) increased simultaneously (Pi: 0.19 (0.15-0.23) mmol/L, P < 0.001, TmP/GFR: 0.20 (0.16-0.23) mmol/L, P < 0.001). In summary, cinacalcet effectively controlled hypercalcemic hyperparathyroidism in KTRs in the long-term and increased low Pi levels without causing hyperphosphatemia, pointing towards a novel indication for the use of cinacalcet in KTRs.
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Cseprekál O, Kis E, Dégi AA, Kerti A, Szabó AJ, Reusz GS. Bone metabolism and arterial stiffness after renal transplantation. Kidney Blood Press Res 2014; 39:507-15. [PMID: 25531154 DOI: 10.1159/000368461] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS To assess the relationship between bone and vascular disease and its changes over time after renal transplantation. Metabolic bone disease (MBD) is common in chronic kidney disease (CKD) and is associated with cardiovascular (CV) disease. Following transplantation (Tx), improvement in CV disease has been reported; however, data regarding changes in bone disease remain controversial. METHODS Bone turnover and arterial stiffness (pulse wave velocity (PWV)) were assessed in 47 Tx patients (38 (3-191) months after Tx). RESULTS Bone alkaline phosphatase (BALP), osteocalcin (OC) and beta-crosslaps were significantly higher in Tx patients, and decreased significantly after one year. There was a negative correlation between BALP, OC and steroid administered (r = -0.35; r = -0.36 respectively). PWV increased in the Tx group (1.15 SD). In patients with a follow up of <24 months, PWV was correlated with BALP and beta-crosslaps (r=0.53; r = 0.69 respectively) while in the ≥24 months group, PWV was correlated with cholesterol (r=0.38). CONCLUSIONS Increased bone turnover and arterial stiffness are present following kidney transplantation. While bone turnover decreases with time, arterial stiffness correlates initially with bone turnover, after which the influence of cholesterol becomes significant. Non-invasive estimation of bone metabolism and arterial stiffness may help to assess CKD-MBD following renal transplantation.
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Affiliation(s)
- Orsolya Cseprekál
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
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Dounousi E, Leivaditis K, Eleftheriadis T, Liakopoulos V. Osteoporosis after renal transplantation. Int Urol Nephrol 2014; 47:503-11. [PMID: 25384432 DOI: 10.1007/s11255-014-0862-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 10/19/2014] [Indexed: 02/07/2023]
Abstract
Bone loss and fracture are serious sequelae of kidney transplantation, associated with morbidity, mortality and high economic costs. The pathogenesis of post-transplantation bone loss is multifactorial and complex. Pre-existing bone mineral disease is responsible for a significant part, but it is aggravated by risk factors emerging after renal transplantation with immunosuppressive agents being one of the key contributors. The decrease in bone mass is particularly prominent during the first 6-12 months after transplantation, continuing at a lower rate thereafter. Bone mineral density measurements do not predict bone histology and bone biopsy findings reveal heterogeneous lesions, which vary according to time after transplantation. Currently, vitamin D and bisphosphonates are the most extensively tested therapeutic agents against this accelerated bone loss in renal transplant recipients. Both of these agents have proven effective, but there is no evidence that they decrease fracture risk. More studies are needed to examine the complex pathophysiologic mechanisms implicated in this population, as well as the effects of different therapeutic interventions on bone disorders after kidney transplantation.
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Affiliation(s)
- Evangelia Dounousi
- Division of Nephrology, Department of Internal Medicine, School of Health Sciences, University Hospital of Ioannina, University of Ioannina, Ioannina, Greece
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Coyne DW, Delos Santos R. Evaluating the safety and rationale for cinacalcet posttransplant hyperparathyroidism and hypercalcemia. Am J Transplant 2014; 14:2446-7. [PMID: 25223316 DOI: 10.1111/ajt.12913] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 07/01/2014] [Accepted: 07/01/2014] [Indexed: 01/25/2023]
Affiliation(s)
- D W Coyne
- Renal Division, Washington University, St. Louis, MO
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Persistence of bone and mineral disorders 2 years after successful kidney transplantation. Transplantation 2014; 96:290-6. [PMID: 23823648 DOI: 10.1097/tp.0b013e3182985468] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Studies that have conducted bone biopsies after kidney transplantation are scarce, and the results are conflicting. METHODS We evaluate the bone histomorphometry, in vitro proliferation, and alkaline phosphatase expression in osteoblasts isolated from bone biopsies from 27 kidney transplant patients. The patients had preserved renal function and were treated with the same immunosuppressive therapy, receiving a minimum dose of corticosteroids. RESULTS The biochemical analysis revealed that 41% of the patients presented with hypercalcemia, 26% presented with hypophosphatemia, and hypovitaminosis D was detected in 63%. The histomorphometric analysis showed a reduced trabecular number and increased trabecular separation, mineral apposition rate, and mineralization lag time, as well as higher osteoid surface, osteoblastic surface, resorption surface, and osteoclastic surface and a lower mineralizing surface, compared with the controls. Based on the TMV classification, bone turnover was normal in 48%, high in 26%, and low in 26% of patients. Bone mineralization was delayed in 48% of the patients, and 58% of the patients with hypovitaminosis D presented with delayed bone mineralization. Bone volume was low in 37% of the patients. The osteoblasts from patients exhibited a higher degree of proliferation compared with those from controls. CONCLUSION Eight-two percent of our patients presented with alterations in at least one of the TMV parameters. Persistence of hyperparathyroidism, hypovitaminosis D, and immunosuppressive drugs may have influenced osteoblast function, which would explain many of the bone alterations found in these patients.
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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: 72] [Impact Index Per Article: 6.5] [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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Alshayeb HM, Josephson MA, Sprague SM. CKD-mineral and bone disorder management in kidney transplant recipients. Am J Kidney Dis 2012; 61:310-25. [PMID: 23102732 DOI: 10.1053/j.ajkd.2012.07.022] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 07/09/2012] [Indexed: 12/11/2022]
Abstract
Kidney transplantation, the most effective treatment for the metabolic abnormalities of chronic kidney disease (CKD), only partially corrects CKD-mineral and bone disorders. Posttransplantation bone disease, one of the major complications of kidney transplantation, is characterized by accelerated loss of bone mineral density and increased risk of fractures and osteonecrosis. The pathogenesis of posttransplantation bone disease is multifactorial and includes the persistent manifestations of pretransplantation CKD-mineral and bone disorder, peritransplantation changes in the fibroblast growth factor 23-parathyroid hormone-vitamin D axis, metabolic perturbations such as persistent hypophosphatemia and hypercalcemia, and the effects of immunosuppressive therapies. Posttransplantation fractures occur more commonly at peripheral than central sites. Although there is significant loss of bone density after transplantation, the evidence linking posttransplantation bone loss and subsequent fracture risk is circumstantial. Presently, there are no prospective clinical trials that define the optimal therapy for posttransplantation bone disease. Combined pharmacologic therapy that targets multiple components of the disordered pathways has been used. Although bisphosphonate or calcitriol therapy can preserve bone mineral density after transplantation, there is no evidence that these agents decrease fracture risk. Moreover, bisphosphonates pose potential risks for adynamic bone disease.
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Affiliation(s)
- Hala M Alshayeb
- Department of Medicine, Section of Nephrology, University of Chicago, Chicago, IL, 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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Messa P, Cafforio C, Alfieri C. Clinical impact of hypercalcemia in kidney transplant. Int J Nephrol 2011; 2011:906832. [PMID: 21760999 PMCID: PMC3132802 DOI: 10.4061/2011/906832] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Revised: 03/31/2011] [Accepted: 04/20/2011] [Indexed: 12/20/2022] Open
Abstract
Hypercalcemia (HC) has been variably reported in kidney transplanted (KTx) recipients (5–15%). Calcium levels peak around the 3rd month after KTx and thereafter slightly reduce and stabilize. Though many factors have been claimed to induce HC after KTx, the persistence of posttransplant hyperparathyroidism (PT-HPT) of moderate-severe degree is universally considered the first causal factor. Though not proven, there are experimental and clinical suggestions that HC can adversely affect either the graft (nephrocalcinosis) and other organs or systems (vascular calcifications, erythrocytosis, pancreatitis, etc.). However, there is no conclusive evidence that correction of serum calcium levels might avoid the occurrence of these claimed clinical effects of HC. The best way to reduce the occurrence of HC after KTx is to treat as best we can the secondary hyperparathyroidism (SHP) during the uraemic stages. The indication to Parathyroidectomy (PTX), either before or after KTx, in order to prevent or to treat, respectively, HC after KTx, is still a matter of debate which has been revived by the availability of the calcimimetic cinacalcet for the treatment of PT-HPT. However, we still need to better clarify many points as regards the potential adverse effects related to either PTX or cinacalcet use in this clinical set, and we are waiting for the results of future randomized controlled trials to achieve some more definite conclusions on this topic.
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Affiliation(s)
- Piergiorgio Messa
- Nefrologia, Dialisi e Trapianto Renale, Ospedale Maggiore-Policlinico-Mangiagalli-Regina Elena, IRCCS, 20122 Milano, Italy
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Smalcelj R, Kusec V. Impaired regulation of calcium excretion in kidney transplant recipients. Wien Klin Wochenschr 2011; 123:334-9. [PMID: 21667092 DOI: 10.1007/s00508-011-1575-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Accepted: 03/07/2011] [Indexed: 10/18/2022]
Abstract
Disorders of mineral metabolism and hypercalcemia are frequent in kidney transplant recipients. Calcium to creatinine (Ca/Cr) clearance ratio was used as a criterion to distinguish between different calcium metabolism disorders. The study comprised 91 (53 men, 38 women) kidney recipients aged 23-70 years, with creatinine clearance (CrCl) >60 ml/min. The following parameters related to mineral metabolism were measured in serum: iPTH, total alkaline phosphatase (tALP), telopeptide (bone degradation marker, CTX), 25(OH)D(3), total and ionized calcium, Ca(++), Pi, creatinine (Cr). Creatinine and Ca were also determined in urine, as well as Ca/Cr clearance ratio. According to the Ca/Cr clearance ratio, patients were divided into three groups as follows: <0.01 (found in disorders caused by reduced calcium-sensing receptor sensitivity, N = 30), 0.01-0.02 (normal value, N = 45), and >0.02 (found in hyperparathyroidism, N = 16). In the group of patients with Ca/Cr clearance ratio <0.01, seven patients had hypercalcemia, and four patients had hypercalcemia and elevated iPTH. It seems that impairment of renal calcium excretion may occur in kidney transplant recipients with good kidney function. Inappropriately low calciuria and impaired sensitivity of calcium-sensing receptor may be pathogenetic factors causing hypercalcemia in kidney transplant recipients.
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Affiliation(s)
- Ruzica Smalcelj
- Department of Dialysis, Zagreb University Hospital Center Zagreb, Zagreb, Croatia.
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Copley JB, Wüthrich RP. Therapeutic management of post-kidney transplant hyperparathyroidism. Clin Transplant 2011; 25:24-39. [PMID: 20572835 DOI: 10.1111/j.1399-0012.2010.01287.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Left uncontrolled, persistent post-kidney transplant hyperparathyroidism (HPT) may lead to or exacerbate pre-existing bone and cardiovascular disease. Parathyroidectomy has long been the primary treatment option for long-term uncontrolled HPT in post-kidney transplant patients. However, patients with contraindications for surgery and parathyroidectomy-associated complications, including graft loss, highlight the need for other approaches. Conventional medical therapies have limited impact on serum calcium (Ca) and parathyroid hormone (PTH) levels. Bisphosphonates and calcitonin, used to spare bone loss, and phosphorus supplementation, to correct hypophosphatemia, do not directly regulate PTH or Ca. Although vitamin D supplementation can reduce PTH, it is often contraindicated because of hypercalcemia. Studies of the calcimimetic cinacalcet in patients with post-kidney transplant HPT suggest that it can rapidly reduce serum PTH and Ca concentrations while increasing serum phosphorus concentrations toward the normal range. Although the clearest application for cinacalcet is the non-surgical treatment of hypercalcemic patients with persistent HPT, current indications for other transplant patients are as yet uncertain. Further studies are needed to determine the utility of cinacalcet in patients with spontaneous resolution of HPT or low bone turnover. This review discusses the pathophysiology of post-kidney transplant HPT, associated complications, and current options for clinical management.
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Brodersen LA, Nielsen PR, Thiesson HC, Marckmann P. Vitamin D status in children and adolescents with kidney transplants. Pediatr Transplant 2011; 15:384-9. [PMID: 21366811 DOI: 10.1111/j.1399-3046.2011.01493.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Hypovitaminosis D is highly prevalent in adult kidney-transplanted patients. The knowledge of vitamin D status in kidney-transplanted children and adolescents is sparse. The present study investigated the vitamin D status of a cohort of kidney-transplanted children and adolescents, and the association between vitamin D status and plasma concentrations of PTH, ionized calcium, and phosphate. The study included 35 patients with a functioning graft. Their mean age was 12.0 yr, and the mean graft age was 2.8 yr. Forty percent of the patients were vitamin D insufficient (P-25-hydroxyvitamin D 40-75 nm), and 14% were deficient (P-25-hydroxyvitamin D < 40 nm). S-25-hydroxyvitamin D was inversely associated with PTH (p = 0.02) and positively associated with S-1,25-dihydroxyvitamin D (p = 0.02). There was no significant association between S-1,25-dihydroxyvitamin D and PTH. In conclusion, we found hypovitaminosis D in 54% of the study population despite the fact that samples were collected in spring and summer months. Hypovitaminosis D was associated with adverse effects on PTH and 1,25-dihydroxyvitamin D. Our data suggest that it is warranted to monitor vitamin D status of kidney-transplanted children and adolescents and indicate that correction of hypovitaminosis D might have favorable effects on calcium-phosphate metabolism.
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Baker R, Jardine A, Andrews P. Renal Association Clinical Practice Guideline on post-operative care of the kidney transplant recipient. Nephron Clin Pract 2011; 118 Suppl 1:c311-47. [PMID: 21555902 DOI: 10.1159/000328074] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Accepted: 02/05/2011] [Indexed: 11/19/2022] Open
Affiliation(s)
- R Baker
- Renal Unit, Lincoln Wing, St. James's University Hospital, Beckett Street, Leeds.
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The effect of cinacalcet on bone remodeling and renal function in transplant patients with persistent hyperparathyroidism. Transplantation 2011; 91:560-5. [PMID: 21192318 DOI: 10.1097/tp.0b013e3182079431] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Parathyroidectomy is associated with renal functional losses in transplant patients; cinacalcet offers an attractive alternative. METHODS We performed a prospective observational study in 58 patients with persisting hyperparathyroidism after renal transplantation (Ca≥2.6 mmol/L) and impaired renal transplant function (estimated glomerular filtration rate [eGFR] <50 mL/min). The patients received 30 to 90 mg cinacalcet for 12 months with the target to normalize serum Ca. We measured parathyroid hormone (PTH), serum Ca, serum phosphorus, alkaline phosphatase, bone-specific alkaline phosphatase, osteocalcin, and telopeptide at 0, 1, 2, 3, 6, 9, and 12 months of cinacalcet treatment. Fractional excretion of calcium and phosphorus (n=24) were monitored at 0 and 1 month. RESULTS At inclusion, creatinine was 181±70 μmol/L, eGFR 43±19 mL/min, PTH 371±279 pg/mL, and Ca 2.73±0.22 mmol/L. We observed nephrocalcinosis in 58% of biopsied patients at enrollment. After cinacalcet, Ca decreased significantly and normalized at nearly any measurement. Phosphorus increased significantly at months 1, 9, and 12. PTH decreased significantly, but only at months 9 and 12 and did not normalize. Bone-specific alkaline phosphatase increased significantly (>normal) by month 12. eGFR decreased and serum creatinine increased at all time points. The Δ(creatinine) % increase correlated significantly with the Δ(PTH) % decrease at month 1 and 12. Telopeptide and alkaline phosphatase correlated with PTH and telopeptide also correlated with serum creatinine. CONCLUSION Calcium-phosphorus homeostasis in hypercalcemic renal transplant patients normalizes under cinacalcet and PTH decreases, albeit not to normal. The renal functional decline could be PTH mediated, analogous to the effects observed after parathyroidectomy.
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Sakhaee K. Osteoporosis following organ transplantation: pathogenesis, diagnosis and management. Expert Rev Endocrinol Metab 2011; 6:157-176. [PMID: 30290452 DOI: 10.1586/eem.10.86] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Organ transplantation has become popular for the management of various chronic illnesses. With the advent of modern immunosuppressive treatments, the longevity of transplant recipients has increased. Consequently, morbid complications such as osteoporosis and bone fractures are seen at an increasing frequency in this population. In most transplant recipients, bone mineral density (BMD) falls shortly after transplantation. However, bone fracture rate plateaus in all except for post-renal transplant patients. Although the underlying pathophysiologic mechanism for this difference is not fully understood, potential mechanisms for sustained bone loss in renal transplant recipients may be persistent phosphorus wasting and defective bone mineralization. Current treatment regimens are based on studies in a small numbers of subjects with BMD as the primary outcome. Although BMD is recognized as a gold standard in the assessment of bone fracture risk, to date, its association with bone fracture risk in the general post-transplant population is not robust. Therefore, randomized controlled trials with bone fracture as the primary end point are crucial. The development of noninvasive bone markers in distinguishing bone turnover and bone mineralization status is also pivotal since skeletal lesions are heterogeneous in various organ transplantations. The elucidation of these underlying skeletal lesions is necessary for the consideration of selective treatment in this population.
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Affiliation(s)
- Khashayar Sakhaee
- a UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8885, USA.
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Copley JB, Germain M, Stern L, Pankewycz O, Katznelson S, Shah T, Wang O, Turner SA, Sprague SM. Evaluation of cinacalcet HCl treatment after kidney transplantation. Transplant Proc 2011; 42:2503-8. [PMID: 20832532 DOI: 10.1016/j.transproceed.2010.04.052] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2009] [Revised: 02/02/2010] [Accepted: 04/08/2010] [Indexed: 11/24/2022]
Abstract
BACKGROUND Hyperparathyroidism often remains or develops after kidney transplantation. Vitamin D sterol used as treatment for an elevated parathyroid hormone (PTH) level and associated bone disease may be contraindicated due to hypercalcemia. The calcimimetic cinacalcet HCl (cinacalcet), which lowers PTH and calcium (Ca) in chronic kidney disease patients, may represent an alternate therapeutic modality. METHODS This multicenter, retrospective, observational study examined 41 kidney transplant patients receiving cinacalcet for ≥3 months starting ≥3 months posttransplantation. Levels of intact PTH, Ca, and phosphorus (P) were examined during the assessment phase (3-6 months after initiation). RESULTS Median PTH decreased 21.8% during the assessment phase (P < .001), with 32.5% of patients exhibiting a ≥30% decrease in PTH from baseline. Median Ca decreased 6.8% (P < .0001). Median serum P rose 10.0% (P = .0124), but remained within normal limits. The estimated glomerular filtration rate was stable throughout the study. CONCLUSIONS Cinacalcet may be useful for the treatment of hyperparathyroidism after kidney transplantation. Randomized, prospectively designed clinical trials are required to confirm these results.
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Affiliation(s)
- J B Copley
- Cleveland Clinic Florida, Weston, Florida 33331, USA.
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Seeherunvong W, Wolf M. Tertiary excess of fibroblast growth factor 23 and hypophosphatemia following kidney transplantation. Pediatr Transplant 2011; 15:37-46. [PMID: 20946192 PMCID: PMC3022970 DOI: 10.1111/j.1399-3046.2010.01405.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Hypophosphatemia caused by inappropriate urinary phosphate wasting is a frequent metabolic complication of the early period following kidney transplantation. Although previously considered to be caused by tertiary hyperparathyroidism, recent evidence suggests a primary role for persistently elevated circulating levels of the phosphorus-regulating hormone, FGF23. In the setting of a healthy renal allograft, markedly increased FGF23 levels from the dialysis period induce renal phosphate wasting and inhibition of calcitriol production, which contribute to hypophosphatemia. While such tertiary FGF23 excess and resultant hypophosphatemia typically abates within the first few weeks to months post-transplant, some recipients manifest persistent renal phosphate wasting. Furthermore, increased FGF23 levels have been associated with increased risk of kidney disease progression, cardiovascular disease, and death outside of the transplant setting. Whether tertiary FGF23 excess is associated with adverse transplant outcomes is unknown. In this article, we review the physiology of FGF23, summarize its relationship with hypophosphatemia after kidney transplantation, and speculate on its potential impact on long-term outcomes of renal allograft recipients.
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Affiliation(s)
- Wacharee Seeherunvong
- Division of Pediatric Nephrology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida
| | - Myles Wolf
- Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
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Wesseling-Perry K, Bacchetta J. CKD-MBD after kidney transplantation. Pediatr Nephrol 2011; 26:2143-51. [PMID: 21394466 PMCID: PMC3203246 DOI: 10.1007/s00467-011-1829-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Revised: 02/11/2011] [Accepted: 02/12/2011] [Indexed: 01/01/2023]
Abstract
Successful kidney transplantation corrects many of the metabolic abnormalities associated with chronic kidney disease (CKD); however, skeletal and cardiovascular morbidity remain prevalent in pediatric kidney transplant recipients and current recommendations from the Kidney Disease Improving Global Outcomes (KDIGO) working group suggest that bone disease-including turnover, mineralization, volume, linear growth, and strength-as well as cardiovascular disease be evaluated in all patients with CKD. Although few studies have examined bone histology after renal transplantation, current data suggest that bone turnover and mineralization are altered in the majority of patients and that biochemical parameters are poor predictors of bone histology in this population. Dual energy X-ray absorptiometry (DXA) scanning, although widely performed, has significant limitations in the pediatric transplant population and values have not been shown to correlate with fracture risk; thus, DXA is not recommended as a tool for the assessment of bone density. Newer imaging techniques, including computed tomography (quantitative CT (QCT), peripheral QCT (pQCT), high resolution pQCT (HR-pQCT) and magnetic resonance imaging (MRI)), which provide volumetric assessments of bone density and are able to discriminate bone microarchitecture, show promise in the assessment of bone strength; however, future studies are needed to define the value of these techniques in the diagnosis and treatment of renal osteodystrophy in pediatric renal transplant recipients.
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Affiliation(s)
- Katherine Wesseling-Perry
- Department of Pediatrics, David Geffen School of Medicine at UCLA, A2-383 MDCC, 650 Charles Young Drive, Los Angeles, CA 90095, USA.
| | - Justine Bacchetta
- Department of Pediatrics, David Geffen School of Medicine at UCLA, A2-383 MDCC, 650 Charles Young Drive, Los Angeles, CA 90095 USA
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