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Magagnoli L, Ciceri P, Cozzolino M. Secondary hyperparathyroidism in chronic kidney disease: pathophysiology, current treatments and investigational drugs. Expert Opin Investig Drugs 2024; 33:775-789. [PMID: 38881200 DOI: 10.1080/13543784.2024.2369307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 06/13/2024] [Indexed: 06/18/2024]
Abstract
INTRODUCTION Secondary hyperparathyroidism (SHPT) is a common complication of chronic kidney disease (CKD). It begins as an adaptive increase in parathyroid hormone levels to prevent calcium and phosphate derangements. Over time, this condition becomes maladaptive and is associated with increased morbidity and mortality. Current therapies encompass phosphate-lowering strategies, vitamin D analogues, calcimimetics and parathyroidectomy. These approaches harbor inherent limitations, stimulating interest in the development of new drugs for SHPT to overcome these limitations and improve survival and quality of life among CKD patients. AREAS COVERED This review delves into the main pathophysiological mechanisms involved in SHPT, alongside the treatment options that are currently available and under active investigation. Data presented herein stem from a comprehensive search conducted across PubMed, Web of Science, ClinicalTrials.gov and International Clinical Trials Registry Platform (ICTRP) spanning from 2000 onwards. EXPERT OPINION The advancements in investigational drugs for SHPT hold significant promise for enhancing treatment efficacy while minimizing side effects associated with conventional therapies. Although several challenges still hinder their adoption in clinical practice, ongoing research will likely continue to expand the available therapeutic options, refine treatment strategies, and tailor them to individual patient profiles.
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Affiliation(s)
- Lorenza Magagnoli
- Department of Health Sciences, University of Milan, IT, Milano, Italy
| | - Paola Ciceri
- Laboratory of Experimental Nephrology, Department of Health Sciences, University of Milan, IT, Milano, Italy
| | - Mario Cozzolino
- Department of Health Sciences, University of Milan, IT, Milano, Italy
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Daugirdas JT. Comparison of modeled versus reported phosphate removal and modeled versus postdialysis serum phosphate levels in conventional hemodialysis. Semin Dial 2022. [PMID: 35829668 DOI: 10.1111/sdi.13112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 06/21/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND We compared predictions of phosphate removal by a 2-pool kinetic model with measured phosphate removal in spent dialysate as reported by others. METHODS Twenty-six studies were identified that reported phosphate removal in 35 groups of patients. In almost all studies, patients were dialyzed for close to 4 h (range 3 to 6 h). For each study, group mean values of predialysis serum phosphate, body size, dialyzer K0 A urea, blood and dialysate flow rates, and session lengths were input into the kinetic model. Predictions of group mean phosphate removal and postdialysis serum phosphate were compared with reported measured values. RESULTS Mean (by patient group) predicted phosphate removal was 931 ± 170 mg/treatment, somewhat higher (p < 0.001) than the reported measured value, 900 mg ± 287. The ratio of predicted/measured removal averaged 1.15 ± 0.427. In 5/35 patient groups (3/26 studies) the predicted/measured phosphate removal was greater than 1.50. If these groups were excluded, the mean measured phosphate removal was 990 mg versus 966 predicted, with a ratio of predicted/measured removal averaging 0.993. Measured group mean postdialysis serum phosphate values (reported in 25/35) were 2.64 ± 0.54, not significantly different from predicted (2.60 ± 0.24 mg/dl, p = NS). CONCLUSIONS For conventional 4-h dialysis treatments, phosphate removal and postdialysis serum phosphate values predicted by a 2-pool kinetic model are similar to reported measured values.
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Affiliation(s)
- John T Daugirdas
- Department of Medicine, Division of Nephrology, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
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Duque EJ, Elias RM, Moysés RMA. Phosphate balance during dialysis and after kidney transplantation in patients with chronic kidney disease. Curr Opin Nephrol Hypertens 2022; 31:326-331. [PMID: 35703226 DOI: 10.1097/mnh.0000000000000802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW In patients with chronic kidney disease (CKD), hyperphosphatemia is associated with several adverse outcomes, including bone fragility and progression of kidney and cardiovascular disease. However, there is a knowledge gap regarding phosphate balance in CKD. This review explores its current state, depending on the stage of CKD, dialysis modalities, and the influence of kidney transplantation. RECENT FINDINGS Adequate phosphate control is one of the goals of treatment for CKD-mineral and bone disorder. However, ongoing studies are challenging the benefits of phosphate-lowering treatment. Nevertheless, the current therapy is based on dietary restriction, phosphate binders, and optimal removal by dialysis. In the face of limited adherence, due to the high pill burden, adjuvant options are under investigation. The recent discovery that intestinal absorption of phosphate is mostly paracellular when the intraluminal concentration is adequate might help explain why phosphate is still well absorbed in CKD, despite the lower levels of calcitriol. SUMMARY Future studies could confirm the benefits of phosphate control. Greater understanding of the complex distribution of phosphate among the body compartments will help us define a better therapeutic strategy in patients with CKD.
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Affiliation(s)
- Eduardo J Duque
- Laboratorio de Fisiopatologia Renal LIM16, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo
| | - Rosilene M Elias
- Laboratorio de Fisiopatologia Renal LIM16, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo
- Postgraduate Program in Medicine, Nove de Julho University, São Paulo, SP, Brazil
| | - Rosa M A Moysés
- Laboratorio de Fisiopatologia Renal LIM16, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo
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Jadav PR, Husain SA, Mohan S, Crew R. Non calcium phosphate binders - Is there any evidence of benefit. Curr Opin Nephrol Hypertens 2022; 31:288-296. [PMID: 35266882 DOI: 10.1097/mnh.0000000000000796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Low-level evidence and opinion-based clinical practice guidelines highlight the substantial uncertainty in the practice patterns of hyperphosphatemia management in patients with chronic kidney disease (CKD). This manuscript reviews the evidence for the choice of phosphate binders and its impact on clinical outcomes. RECENT FINDINGS Phosphate binders are among the most common medications prescribed for patients on dialysis. Clinical practice guidelines recommend lowering phosphate levels toward normal range and restricting calcium-based binders in all CKD patients. There is substantial gap in the evidence underlying these recommendations with lack of any placebo-controlled, randomized trials showing survival benefits for any class of phosphate-binders. Despite the lack of evidence for specific phosphate target or if lowering phosphate improves survival, use of phosphate binders has remained central strategy in approach to hyperphosphatemia. Use of binders has added to the cost and contributed significant pill burden. Restriction of calcium-based binders to avoid positive calcium balance and consequent vascular calcification risk has a physiological rationale and weight of observational studies. SUMMARY There is currently no conclusive evidence that definitively guides the choice of any specific binders for management of hyperphosphatemia in patients with CKD. Use of noncalcium-based binders has a theoretical advantage in restricting total calcium intake to decrease the risk of vascular calcification but no proven benefits for mortality.
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Affiliation(s)
- Paresh R Jadav
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY
| | - S Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY
- The Columbia University Renal Epidemiology (CURE) Group
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY
- The Columbia University Renal Epidemiology (CURE) Group
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Russell Crew
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY
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Stremke ER, Trevino L, Doshi S, Moorthi RN, Hill Gallant KM, Moe SM. Postdialysis serum phosphate equilibrium in hemodialysis patients on a controlled diet and no binders. Hemodial Int 2022; 26:255-263. [PMID: 34964250 PMCID: PMC9096807 DOI: 10.1111/hdi.12999] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Studies evaluating the change in serum phosphate post hemodialysis (HD) demonstrate an initial decline during dialysis but a rebound post dialysis. However, previous studies were done on usual diet and phosphate binders, with limited number of blood draws, confounding conclusions. We determined serum phosphate reduction, rebound, and equilibrium over 48 h in HD patients consuming a controlled, low phosphorus diet without binders. METHODS Serum phosphate (mg/dL) was analyzed before and after a HD treatment and frequently during the ensuing 48 h intradialytic period in the clinical research unit. Thirteen subjects were enrolled and had been off phosphate binders for 10 days and consumed a standardized low phosphate (900 mg/day) diet for 3 weeks prior to the assessments. Linear regression was used to determine relationships between the pre-HD serum phosphate, decline post-HD (post-HD drop); and a 48 h area under curve (AUC) using the trapezoidal method as a measure of overall phosphate levels from the end of dialysis to 48 h post dialysis. Repeated Measures ANOVA with Dunnett's posthoc test was used to determine rebound. RESULTS Five of 13 subjects returned to >90% of their pre-HD serum phosphate within the first 24 h post-HD, and serum phosphate was 94 ± 0.11% (range 63%-113%) by 48 h after the completion of HD. The 48 h AUC of serum phosphate during the interdialytic period was correlated with both pre dialysis phosphorus (r = 0.85; p = 0.0002) and the pre-post drop in serum phosphate during dialysis (r = 0.69; p = 0.0085). In contrast, the net ultrafiltration was not related to the 48 h AUC of serum phosphorus (r = 0.20; p = 0.51). CONCLUSIONS In hemodialysis patients on standard low phosphorus diet and no phosphate binders, the interdialytic serum phosphorus level, assessed as AUC, is determined by the pre dialysis phosphorus and net-change in serum phosphorus during the dialysis treatment, but not the ultrafiltration volume [Correction added on 25 January, after first online publication: In the last sentence of the Abstract, the word "potassium" has been replaced with "phosphorus" to improve accuracy.].
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Affiliation(s)
- Elizabeth R Stremke
- Department of Nutrition Science, Purdue University, West Lafayette, Indiana, USA
- Indiana Clinical and Translational Science Institute, Indiana University, Indianapolis, Indiana, USA
| | - Laurie Trevino
- Indiana Clinical and Translational Science Institute, Indiana University, Indianapolis, Indiana, USA
| | - Simit Doshi
- Department of Medicine/Division of Nephrology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ranjani N Moorthi
- Department of Medicine/Division of Nephrology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kathleen M Hill Gallant
- Department of Nutrition Science, Purdue University, West Lafayette, Indiana, USA
- Department of Food Science and Nutrition, University of Minnesota, Saint Paul, Minnesota, USA
| | - Sharon M Moe
- Indiana Clinical and Translational Science Institute, Indiana University, Indianapolis, Indiana, USA
- Department of Medicine/Division of Nephrology, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Roudebush Veterans Administration Medical Center, Indianapolis, Indiana, USA
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OUP accepted manuscript. Clin Chem 2022. [DOI: 10.1093/clinchem/hvac059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Zhang W, Du Q, Xiao J, Bi Z, Yu C, Ye Z, Wang M, Chen J. Modification and Validation of the Phosphate Removal Model: A Multicenter Study. Kidney Blood Press Res 2021; 46:53-62. [PMID: 33477164 DOI: 10.1159/000511375] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/05/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Our research group has previously reported a noninvasive model that estimates phosphate removal within a 4-h hemodialysis (HD) treatment. The aim of this study was to modify the original model and validate the accuracy of the new model of phosphate removal for HD and hemodiafiltration (HDF) treatment. METHODS A total of 109 HD patients from 3 HD centers were enrolled. The actual phosphate removal amount was calculated using the area under the dialysate phosphate concentration time curve. Model modification was executed using second-order multivariable polynomial regression analysis to obtain a new parameter for dialyzer phosphate clearance. Bias, precision, and accuracy were measured in the internal and external validation to determine the performance of the modified model. RESULTS Mean age of the enrolled patients was 63 ± 12 years, and 67 (61.5%) were male. Phosphate removal was 19.06 ± 8.12 mmol and 17.38 ± 6.75 mmol in 4-h HD and HDF treatments, respectively, with no significant difference. The modified phosphate removal model was expressed as Tpo4 = 80.3 × C45 - 0.024 × age + 0.07 × weight + β × clearance - 8.14 (β = 6.231 × 10-3 × clearance - 1.886 × 10-5 × clearance2 - 0.467), where C45 was the phosphate concentration in the spent dialysate measured at the 45th minute of HD and clearance was the phosphate clearance of the dialyzer. Internal validation indicated that the new model was superior to the original model with a significantly smaller bias and higher accuracy. External validation showed that R2, bias, and accuracy were not significantly different than those of internal validation. CONCLUSIONS A new model was generated to quantify phosphate removal by 4-h HD and HDF with a dialyzer surface area of 1.3-1.8 m2. This modified model would contribute to the evaluation of phosphate balance and individualized therapy of hyperphosphatemia.
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Affiliation(s)
- Weichen Zhang
- Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Qiuna Du
- Nephrology, Tongji Hospital, Tongji University, Shanghai, China
| | - Jing Xiao
- Nephrology, Huadong Hospital, Fudan University, Shanghai, China
| | - Zhaori Bi
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Chen Yu
- Nephrology, Tongji Hospital, Tongji University, Shanghai, China
| | - Zhibin Ye
- Nephrology, Huadong Hospital, Fudan University, Shanghai, China
| | - Mengjing Wang
- Nephrology, Huashan Hospital, Fudan University, Shanghai, China,
| | - Jing Chen
- Nephrology, Huashan Hospital, Fudan University, Shanghai, China.,National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
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Chazot G, Lemoine S, Kocevar G, Kalbacher E, Sappey-Marinier D, Rouvière O, Juillard L. Intracellular Phosphate and ATP Depletion Measured by Magnetic Resonance Spectroscopy in Patients Receiving Maintenance Hemodialysis. J Am Soc Nephrol 2021; 32:229-237. [PMID: 33093193 PMCID: PMC7894675 DOI: 10.1681/asn.2020050716] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 09/13/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The precise origin of phosphate that is removed during hemodialysis remains unclear; only a minority comes from the extracellular space. One possibility is that the remaining phosphate originates from the intracellular compartment, but there have been no available data from direct assessment of intracellular phosphate in patients undergoing hemodialysis. METHODS We used phosphorus magnetic resonance spectroscopy to quantify intracellular inorganic phosphate (Pi), phosphocreatine (PCr), and βATP. In our pilot, single-center, prospective study, 11 patients with ESKD underwent phosphorus (31P) magnetic resonance spectroscopy examination during a 4-hour hemodialysis treatment. Spectra were acquired every 152 seconds during the hemodialysis session. The primary outcome was a change in the PCr-Pi ratio during the session. RESULTS During the first hour of hemodialysis, mean phosphatemia decreased significantly (-41%; P<0.001); thereafter, it decreased more slowly until the end of the session. We found a significant increase in the PCr-Pi ratio (+23%; P=0.001) during dialysis, indicating a reduction in intracellular Pi concentration. The PCr-βATP ratio increased significantly (+31%; P=0.001) over a similar time period, indicating a reduction in βATP. The change of the PCr-βATP ratio was significantly correlated to the change of depurated Pi. CONCLUSIONS Phosphorus magnetic resonance spectroscopy examination of patients with ESKD during hemodialysis treatment confirmed that depurated Pi originates from the intracellular compartment. This finding raises the possibility that excessive dialytic depuration of phosphate might adversely affect the intracellular availability of high-energy phosphates and ultimately, cellular metabolism. Further studies are needed to investigate the relationship between objective and subjective effects of hemodialysis and decreases of intracellular Pi and βATP content. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Intracellular Phosphate Concentration Evolution During Hemodialysis by MR Spectroscopy (CIPHEMO), NCT03119818.
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Affiliation(s)
- Guillaume Chazot
- Service de néphrologie et d’exploration fonctionnelle rénale, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Sandrine Lemoine
- Service de néphrologie et d’exploration fonctionnelle rénale, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
- CARMEN U1060 Institut National de la Santé et de la Recherche Médicale (Cardiovascular Metabolisme Nutrition), Université de Lyon, Université Claude Bernard, INSA de Lyon, Bron, France
| | - Gabriel Kocevar
- CREATIS (Centre de Recherche et d'Applications en Traitement de l'Image et du Signal) Unité Mixte de Recherche 5220 Centre National de la Recherche Scientifique and U1206 Institut National de la Santé et de la Recherche Médicale, Université de Lyon, Université Claude Bernard, INSA (Institut National Des Sciences Appliquées) de Lyon, Villeurbanne, France
| | - Emilie Kalbacher
- Service de néphrologie et d’exploration fonctionnelle rénale, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Dominique Sappey-Marinier
- CREATIS (Centre de Recherche et d'Applications en Traitement de l'Image et du Signal) Unité Mixte de Recherche 5220 Centre National de la Recherche Scientifique and U1206 Institut National de la Santé et de la Recherche Médicale, Université de Lyon, Université Claude Bernard, INSA (Institut National Des Sciences Appliquées) de Lyon, Villeurbanne, France
- CERMEP-Imagerie du vivant (Centre d'Etude et de Recherche Médicale par Emission de Positons), Université de Lyon, Bron, France
| | - Olivier Rouvière
- Service de radiologie, Hôpital Édouard-Herriot, Hospices Civils de Lyon, Lyon, France
- Labtau U1032 Institut National de la Santé et de la Recherche Médicale, Université de Lyon, Université Claude Bernard, Villeurbanne, France
| | - Laurent Juillard
- Service de néphrologie et d’exploration fonctionnelle rénale, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
- CARMEN U1060 Institut National de la Santé et de la Recherche Médicale (Cardiovascular Metabolisme Nutrition), Université de Lyon, Université Claude Bernard, INSA de Lyon, Bron, France
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Milazi M, Douglas C, Bonner A. A bundled phosphate control intervention (4Ds) for adults with end-stage kidney disease receiving haemodialysis: A cluster randomized controlled trial. J Adv Nurs 2020; 77:1345-1356. [PMID: 33277736 DOI: 10.1111/jan.14700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 10/18/2020] [Accepted: 11/13/2020] [Indexed: 11/28/2022]
Abstract
AIM To evaluate the effectiveness of a bundled self-management intervention (taking control of your phosphate with the 4Ds) to improve phosphate control among adults receiving haemodialysis. BACKGROUND Hyperphosphataemia occurs in end-stage kidney disease and is managed by diet, drinks, drugs (phosphate binder medication), and dialysis (the 4Ds). Adherence to the 4Ds is challenging for patients. DESIGN A pragmatic cluster randomized controlled trial with repeated measures. METHODS Participants were adults receiving haemodialysis with high serum phosphate (>1.6 mmol/L for at least 3 months) recruited between August 2017 -May 2018. Cluster randomization was according to haemodialysis treatment shifts. The 'teach-back' intervention was designed to improve phosphate control. Expected outcomes were reduced serum phosphate and increased knowledge of phosphate in end-stage kidney disease, self-efficacy and adherence to diet, drugs, and dialysis. RESULTS There were no differences between groups at baseline. Both groups had similar mean serum phosphate over time; at three months, 46% of the intervention group achieved reductions that met the target serum phosphate level compared with 33% of the control group. There were significant improvements in knowledge of phosphate in end-stage kidney disease, self-efficacy and adherence to diet, drugs, and dialysis (missing) in the intervention group compared with control group. CONCLUSION The 4Ds, a bundled self-management intervention, was effective in improving patient confidence and adherence to phosphate control methods. IMPACT The 4Ds intervention bundles together four essential strategies for preventing and controlling hyperphosphataemia in end-stage kidney disease. TRIAL REGISTRATION ACTRN12617000703303 Registered 16/05/2017.
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Affiliation(s)
- Molly Milazi
- School of Nursing, Queensland University of Technology (QUT), Brisbane, Queensland, Australia.,Kidney Health Service, Metro North Hospital and Health Service, Brisbane, Queensland, Australia
| | - Clint Douglas
- School of Nursing, Queensland University of Technology (QUT), Brisbane, Queensland, Australia.,Nursing Chair, Metro North Hospital and Health Service, Brisbane, Queensland, Australia
| | - Ann Bonner
- Kidney Health Service, Metro North Hospital and Health Service, Brisbane, Queensland, Australia.,School of Nursing and Midwifery, Griffith University, Brisbane, Queensland, Australia
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Potluri VS, Sawinski D, Tam V, Shults J, Cohen JB, Wiebe DJ, Shah SP, Berns JS, Reese PP. Effect of Neighborhood Food Environment and Socioeconomic Status on Serum Phosphorus Level for Patients on Chronic Dialysis. J Am Soc Nephrol 2020; 31:2622-2630. [PMID: 32917783 DOI: 10.1681/asn.2020030290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 07/20/2020] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Elevated blood phosphorus levels are common and associated with a greater risk of death for patients receiving chronic dialysis. Phosphorus-rich foods are prevalent in the American diet, and low-phosphorus foods, including fruits and vegetables, are often less available in areas with more poverty. The relative contributions of neighborhood food availability and socioeconomic status to phosphorus control in patients receiving dialysis are unknown. METHODS Using longitudinal data from a national dialysis provider, we constructed hierarchical, linear mixed-effects models to evaluate the relationships between neighborhood food environment or socioeconomic status and serum phosphorus level among patients receiving incident dialysis. RESULTS Our cohort included 258,510 patients receiving chronic hemodialysis in 2005-2013. Median age at dialysis initiation was 64 years, 45% were female, 32% were Black, and 15% were Hispanic. Within their residential zip code, patients had a median of 25 "less-healthy" food outlets (interquartile range, 11-40) available to them compared with a median of four "healthy" food outlets (interquartile range, 2-6). Living in a neighborhood with better availability of healthy food was not associated with a lower phosphorus level. Neighborhood income also was not associated with differences in phosphorus. Patient age, race, cause of ESKD, and mean monthly dialysis duration were most closely associated with phosphorus level. CONCLUSIONS Neither neighborhood availability of healthy food options nor neighborhood income was associated with phosphorus levels in patients receiving chronic dialysis. Modifying factors, such as nutrition literacy, individual-level financial resources, and adherence to diet restrictions and medications, may be more powerful contributors than food environment to elevated phosphorus.
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Affiliation(s)
- Vishnu S Potluri
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Deirdre Sawinski
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Vicky Tam
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Justine Shults
- Department of Biostatistics, Epidemiology and Bioinformatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jordana B Cohen
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology and Bioinformatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Douglas J Wiebe
- Department of Biostatistics, Epidemiology and Bioinformatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Siddharth P Shah
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey S Berns
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania .,Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology and Bioinformatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Clinical, CT and ultrasonographic features of renal secondary hyperparathyroidism in a juvenile dog. VETERINARY RECORD CASE REPORTS 2020. [DOI: 10.1136/vetreccr-2020-001197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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12
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Holden RM, Mustafa RA, Alexander RT, Battistella M, Bevilacqua MU, Knoll G, Mac-Way F, Reslerova M, Wald R, Acott PD, Feltmate P, Grill A, Jindal KK, Karsanji M, Kiberd BA, Mahdavi S, McCarron K, Molnar AO, Pinsk M, Rodd C, Soroka SD, Vinson AJ, Zimmerman D, Clase CM. Canadian Society of Nephrology Commentary on the Kidney Disease Improving Global Outcomes 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder. Can J Kidney Health Dis 2020; 7:2054358120944271. [PMID: 32821415 PMCID: PMC7412914 DOI: 10.1177/2054358120944271] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 06/06/2020] [Indexed: 12/23/2022] Open
Abstract
Purpose of review: (1) To provide commentary on the 2017 update to the Kidney Disease Improving Global Outcomes (KDIGO) 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD); (2) to apply the evidence-based guideline update for implementation within the Canadian health care system; (3) to provide comment on the care of children with chronic kidney disease (CKD); and (4) to identify research priorities for Canadian patients. Sources of information: The KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of CKD-MBD. Methods: The commentary committee co-chairs selected potential members based on their knowledge of the Canadian kidney community, aiming for wide representation from relevant disciplines, academic and community centers, and different geographical regions. Key findings: We agreed with many of the recommendations in the clinical practice guideline on the diagnosis, evaluation, prevention, and treatment of CKD-MBD. However, based on the uncommon occurrence of abnormalities in calcium and phosphate and the low likelihood of severe abnormalities in parathyroid hormone (PTH), we recommend against screening and monitoring levels of calcium, phosphate, PTH, and alkaline phosphatase in adults with CKD G3. We suggest and recommend monitoring these parameters in adults with CKD G4 and G5, respectively. In children, we agree that monitoring for CKD-MBD should begin in CKD G2, but we suggest measuring ionized calcium, rather than total calcium or calcium adjusted for albumin. With regard to vitamin D, we suggest against routine screening for vitamin D deficiency in adults with CKD G3-G5 and G1T-G5T and suggest following population health recommendations for adequate vitamin D intake. We recommend that the measurement and management of bone mineral density (BMD) be according to general population guidelines in CKD G3 and G3T, but we suggest against routine BMD testing in CKD G4-G5, CKD G4T-5T, and in children with CKD. Based on insufficient data, we also recommend against routine bone biopsy in clinical practice for adults with CKD or CKD-T, or in children with CKD, although we consider it an important research tool. Limitations: The committee relied on the evidence summaries produced by KDIGO. The CSN committee did not replicate or update the systematic reviews.
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Affiliation(s)
- Rachel M Holden
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Reem A Mustafa
- Division of Nephrology and Hypertension, Department of Internal Medicine, The University of Kansas Medical Center, Kansas City, USA.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - R Todd Alexander
- Department of Pediatrics and Physiology, University of Alberta, Edmonton, Canada
| | - Marisa Battistella
- University Health Network, Leslie Dan Faculty of Pharmacy, University of Toronto, ON, Canada
| | - Micheli U Bevilacqua
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Greg Knoll
- Division of Nephrology, The Ottawa Hospital, ON, Canada
| | - Fabrice Mac-Way
- Division of Nephrology, CHU de Québec, Hôtel-Dieu de Québec Hospital, Université Laval, Québec City, QC, Canada
| | - Martina Reslerova
- Nephrology Section, St. Boniface General Hospital, University of Manitoba, Winnipeg, Canada
| | - Ron Wald
- Division of Nephrology, St. Michael's Hospital, University of Toronto, ON, Canada
| | - Philip D Acott
- Division of Nephrology, Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | - Patrick Feltmate
- Department of Geriatric Medicine, Dalhousie University, Halifax, NS, Canada
| | - Allan Grill
- Department of Family & Community Medicine, University of Toronto, ON, Canada
| | - Kailash K Jindal
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Meena Karsanji
- Professional Practice, Vancouver Coastal Health, Richmond, BC, Canada
| | - Bryce A Kiberd
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Sara Mahdavi
- Department of Nutritional Sciences, University of Toronto, ON, Canada.,Department of Nephrology, Scarborough Health Network, ON, Canada
| | - Kailee McCarron
- Nova Scotia Renal Program, Nova Scotia Health Authority, Halifax, Canada
| | - Amber O Molnar
- Division of Nephrology, McMaster University, Hamilton, ON, Canada
| | - Maury Pinsk
- Division of Nephrology, Department of Pediatrics & Child Health, University of Manitoba, Winnipeg, Canada
| | - Celia Rodd
- Division of Diabetes & Endocrinology, Department of Pediatrics & Child Health, University of Manitoba, Winnipeg, Canada
| | - Steven D Soroka
- Division of Nephrology, Department of Medicine, Dalhousie University, NSHA Renal Program and Pharmacy Services, Halifax, NS, Canada
| | - Amanda J Vinson
- Division of Nephrology, Dalhousie University, Halifax, NS, Canada
| | - Deborah Zimmerman
- Division of Nephrology, Department of Medicine, University of Ottawa, ON, Canada
| | - Catherine M Clase
- Division of Nephrology, Department of Medicine, Department of Health Research, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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13
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Molony DA, Parameswaran V, Ficociello LH, Mullon C, Kossmann RJ. Sucroferric Oxyhydroxide as Part of Combination Phosphate Binder Therapy among Hemodialysis Patients. KIDNEY360 2020; 1:263-272. [PMID: 35372921 PMCID: PMC8809266 DOI: 10.34067/kid.0000332019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 03/05/2020] [Indexed: 06/14/2023]
Abstract
BACKGROUND Combination therapy with multiple phosphate binders is prescribed to reduce elevated serum phosphorus (sP) concentrations among patients on maintenance hemodialysis. Sucroferric oxyhydroxide (SO), an iron-based phosphate binder, has demonstrated efficacy at reducing sP while also being associated with a low pill burden. Whereas the effects of SO monotherapy have been well characterized in clinical trials and observational cohorts, little is known about the effects of SO-containing combination therapy. METHODS Patients on hemodialysis (N=234) at Fresenius Kidney Care (FKC) who received ≥120 days of uninterrupted phosphate binder combination therapy with SO were included in this retrospective study. Patient data were censored after SO discontinuation, end of care at FKC, or completion of 12 months of follow-up. Quarterly (Q) changes in phosphate binder pill burden, mean sP, and proportion of patients achieving National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-KDOQI)-recommended sP levels (≤5.5 mg/dl) were compared between baseline (-Q1) and follow-up (Q1-Q4). RESULTS Phosphate binder combination therapy with SO was associated with significant increase in the proportion of patients with sP ≤5.5 mg/dl (from 19% at baseline to up to 40% at follow-up; P<0.001) and reduction in sP at all postbaseline time points (from 6.7 mg/dl to 6.2-6.3 mg/dl; P<0.001). Patients on calcium acetate (N=54) and sevelamer (N=94) who added SO therapy at follow-up resulted in a ≥250% increase in patients achieving sP ≤5.5 mg/dl (all P<0.001). Whereas mean phosphate binder pill burden increased with initiation of phosphate binder combination therapy with SO (15.8 pills/d at Q1 versus 12.3 pills/d at -Q1), continued use of SO was associated with down-titration of non-SO phosphate binders such that, by Q4, mean total PB pill burden reduced to 12.3 pills/d. CONCLUSIONS For patients on hemodialysis with uncontrolled hyperphosphatemia, combination therapy with SO may allow for sustained improvements in sP control without adversely affecting phosphate binder pill burden.
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Affiliation(s)
- Donald A. Molony
- Division of Renal Diseases and Hypertension, Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School University of Texas, Houston, Texas; and
| | | | | | - Claudy Mullon
- Fresenius Medical Care Renal Therapies Group, Waltham, Massachusetts
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14
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Tani T, Fujiwara M, Orimo H, Shimizu A, Narisawa S, Pinkerton AB, Millán JL, Tsuruoka S. Inhibition of tissue-nonspecific alkaline phosphatase protects against medial arterial calcification and improves survival probability in the CKD-MBD mouse model. J Pathol 2019; 250:30-41. [PMID: 31509234 DOI: 10.1002/path.5346] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 08/30/2019] [Accepted: 09/05/2019] [Indexed: 01/07/2023]
Abstract
Medial arterial calcification (MAC) is a major complication of chronic kidney disease (CKD) and an indicator of poor prognosis. Aortic overexpression of tissue-nonspecific alkaline phosphatase (TNAP) accelerates MAC formation. The present study aimed to assess whether a TNAP inhibitor, SBI-425, protects against MAC and improves survival probability in a CKD-mineral and bone disorder (MBD) mouse model. CKD-MBD mice were divided in three groups: vehicle, SBI-10, and SBI-30. They were fed a 0.2% adenine and 0.8% phosphorus diet from 14 to 20 weeks of age to induce CKD, followed by a high-phosphorus (0.2% adenine and 1.8% phosphorus) diet for another 6 weeks. At 14-20 weeks of age, mice in the SBI-10 and SBI-30 groups were given 10 and 30 mg/kg SBI-425 by gavage once a day, respectively, while vehicle-group mice were given distilled water as vehicle. Control mice were fed a standard chow (0.8% phosphorus) between the ages of 8 and 20 weeks. Computed tomography imaging, histology, and aortic tissue calcium content revealed that, compared to vehicle animals, SBI-425 nearly halted the formation of MAC. Mice in the control, SBI-10 and SBI-30 groups exhibited 100% survival, which was significantly better than vehicle-treated mice (57.1%). Aortic mRNA expression of Alpl, encoding TNAP, as well as plasma and aortic tissue TNAP activity, were suppressed by SBI-425 administration, whereas plasma pyrophosphate increased. We conclude that a TNAP inhibitor successfully protected the vasculature from MAC and improved survival rate in a mouse CKD-MBD model, without causing any adverse effects on normal skeletal formation and residual renal function. © 2019 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.
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Affiliation(s)
- Takashi Tani
- Department of Nephrology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan.,Department of Metabolism and Nutrition, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Megumi Fujiwara
- Department of Metabolism and Nutrition, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Hideo Orimo
- Department of Metabolism and Nutrition, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Akira Shimizu
- Department of Analytic Human Pathology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Sonoko Narisawa
- Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | | | - José Luis Millán
- Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Shuichi Tsuruoka
- Department of Nephrology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
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15
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Stecz W, Pytlak R, Rymarz A, Niemczyk S. Application of dynamic optimisation for planning a haemodialysis process. BMC Nephrol 2019; 20:236. [PMID: 31266483 PMCID: PMC6604306 DOI: 10.1186/s12882-019-1409-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 06/03/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The aim of the study is to show that optimization tools can be used in planning the haemodialysis process in order to obtain the most effective treatment aimed at removing both urea and phosphorus. To this end we use the IV-compartment model of phosphorus kinetics. METHODS The use of the IV-compartment model of phosphorus kinetics forces us to apply new numerical tools which cope with a rebound phenomenon that can occur during haemodialysis. The proposed algorithm solves optimization problems with various constraints imposed on concentrations of urea and phosphorus. RESULTS We show that the optimization tools are effective in planning haemodialysis processes aimed at achieving desired levels of urea and phosphorus concentrations at the end of these processes. One of the numerical experiments reported in the paper concerns patients data who experienced a rebound phenomenon during haemodialysis due to a low level of phosphorus concentration. CONCLUSION In order to plan haemodialysis processes one should take into account the fact that these processes, in general, are described by different equations in different regions determined by phosphorus concentrations. This follows from the fact that mechanisms modelled by IV-compartment model are activated during dialysis. Therefore, advanced numerical tools have to be used in order to simulate and optimize these processes. The paper shows that these tools can be constructed and effectively applied in planning haemodialysis processes.
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Affiliation(s)
- Wojciech Stecz
- Military University of Technology, Faculty of Cybernetics, Kaliskiego 2, Warsaw, 00-908 Poland
| | - Radoslaw Pytlak
- Warsaw University of Technology, Faculty of Mathematics and Information Science, Koszykowa 75, Warsaw, 00-662 Poland
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16
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Brauer A, Waheed S, Singh T, Maursetter L. Improvement in Hyperphosphatemia Using Phosphate Education and Planning Talks. J Ren Nutr 2019; 29:156-162. [DOI: 10.1053/j.jrn.2018.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 06/04/2018] [Accepted: 06/08/2018] [Indexed: 01/04/2023] Open
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17
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Guida B, Parolisi S, Coco M, Ruoppo T, Veccia R, di Maro M, Trio R, Memoli A, Cataldi M. The impact of a nutritional intervention based on egg white for phosphorus control in hemodialyis patients. Nutr Metab Cardiovasc Dis 2019; 29:45-50. [PMID: 30459073 DOI: 10.1016/j.numecd.2018.09.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 09/18/2018] [Accepted: 09/20/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Here we describe a dietary intervention for hyperphosphatemia in dialysis patients based on the partial replacement of meat and fish, which are one of the main sources of alimentary phosphorous, with egg white, a virtually phosphorous-free protein source. This intervention aims to reduce phosphorous intake without causing protein wasting. PATIENTS AND METHODS As many as 23 hyperphosphatemic patients (15 male and 8 female, mean age 53.0 ± 10.0 years) on chronic standard 4 h, three times weekly, bicarbonate hemodialysis were enrolled in this open-label, randomized controlled trial. Patients in the intervention group were instructed to replace fish or meat with egg white in three meals a week for three months whereas diet was unchanged in the control group. RESULTS Serum phosphate concentrations were significantly lower in the intervention group than in controls after three (4.9 ± 1.0 vs 6.6 ± 0.8; p < 0.001) but not after one month of treatment. Phosphate concentrations decreased more from baseline in the intervention than in the control group both after one (-1,2 ± 1,1 vs 0,5 ± 1,1; p = 0.004) and after three (-1,7 ± 1,1 vs -0,6 ± 1,1; p < 0.001) months of follow-up. No change either in body weight or in body composition assessed with bioelectrical impedance analysis or in serum albumin concentration was observed in either group. CONCLUSION The partial replacement of meat and fish with egg white induces a significant decrease in serum phosphate without causing protein malnutrition and could represent a useful instrument to control serum phosphate levels in hemodialysis patients. CLINICALTRIALS. GOV IDENTIFIER NCT03236701.
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Affiliation(s)
- B Guida
- Department of Clinical Medicine and Surgery, Physiology Nutrition Unit, Federico II University of Naples, Italy; Federico II University Hospital, Naples, Italy.
| | - S Parolisi
- Department of Clinical Medicine and Surgery, Physiology Nutrition Unit, Federico II University of Naples, Italy
| | - M Coco
- Department of Clinical Medicine and Surgery, Physiology Nutrition Unit, Federico II University of Naples, Italy
| | - T Ruoppo
- Department of Clinical Medicine and Surgery, Physiology Nutrition Unit, Federico II University of Naples, Italy
| | - R Veccia
- Department of Clinical Medicine and Surgery, Physiology Nutrition Unit, Federico II University of Naples, Italy
| | - M di Maro
- Department of Clinical Medicine and Surgery, Physiology Nutrition Unit, Federico II University of Naples, Italy
| | - R Trio
- Department of Clinical Medicine and Surgery, Physiology Nutrition Unit, Federico II University of Naples, Italy; Federico II University Hospital, Naples, Italy
| | - A Memoli
- Department of Public Health, Nephrology Section, Federico II University of Naples, Italy; Federico II University Hospital, Naples, Italy
| | - M Cataldi
- Department of Neuroscience, Reproductive Sciences and Dentistry, Division of Pharmacology, Federico II University of Naples, Italy; Federico II University Hospital, Naples, Italy
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18
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Ko GJ, Obi Y, Soohoo M, Chang TI, Choi SJ, Kovesdy CP, Streja E, Rhee CM, Kalantar-Zadeh K. No Survival Benefit in Octogenarians and Nonagenarians with Extended Hemodialysis Treatment Time. Am J Nephrol 2018; 48:389-398. [PMID: 30423584 DOI: 10.1159/000494336] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 09/21/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND The population of elderly end-stage renal disease patients initiating dialysis is rapidly growing. Although longer treatment is supposed to benefit for hemodialysis (HD) patients through more solute clearance and slower fluid removal, it is not yet clear how treatment session length affects mortality risk in octogenarians and nonagenarians. METHODS In a cohort of 112,026 incident HD patients between 2007 and 2011, we examined the association of treatment session length with all-cause mortality, adjusting for demographics and comorbid conditions. We also used restricted spline functions for age to evaluate continuous changes in the association of short (< 210 min) and extended (≥240 min) HD treatment (vs. 210 to < 240 min) with all-cause mortality over continuous age. RESULTS During the first 91 days of dialysis, patients aged ≥80 years tended to have the lowest treatment session length (median [interquartile range] 211 [193-230] min, r > 0.5). Longer treatment was associated with better survival in patients < 65 and 65 to < 80 years but not in octogenarians/nonagenarians. The association of extended treatment (≥240 min) with better survival was attenuated across age and not significant among patients aged ≥80 years with a hazard ratio of 1.10 (95% CI 0.99-1.20). Shorter treatment sessions (< 210 min) was associated with higher mortality across all age groups. CONCLUSION Extended HD was not associated with lower mortality among octogenarians and nonagenarians, while it was associated with better survival among younger patients. Further studies are needed to determine the optimal treatment session length in elderly incident HD patients.
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Affiliation(s)
- Gang Jee Ko
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, Florida, USA
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, Florida, USA
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, Florida, USA
| | - Tae Ik Chang
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, Florida, USA
- Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyangshi, Republic of Korea
| | - Soo Jeong Choi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, Florida, USA
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee, Health Science Center, Memphis, Tennessee, USA
- Nephrology Section, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, Florida, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, Florida, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, Florida, USA,
- Department of Medicine, Long Beach Veteran Affairs Health System, Long Beach, California, USA,
- Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, California, USA,
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19
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Scialla JJ. Evidence basis for integrated management of mineral metabolism in patients with end-stage renal disease. Curr Opin Nephrol Hypertens 2018; 27:258-267. [PMID: 29677006 PMCID: PMC6413862 DOI: 10.1097/mnh.0000000000000417] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Treatment of mineral metabolism is a mainstay of dialysis care including some of its most widely used and costly pharmaceuticals. Although many mineral metabolites are associated with increased risk of mortality, cardiovascular disease, and other morbidities, few clinical trials are available to guide therapy and most focus on single drug approaches. In practice, providers manage many aspects of mineral metabolism simultaneously in integrated treatment approaches that incorporate multiple agents and changes in the dialysis prescription. The present review discusses the rationale and existing evidence for evaluating integrated, as opposed to single drug, approaches in mineral metabolism. RECENT FINDINGS Drugs used to treat mineral metabolism have numerous, and sometimes, opposing effects on biochemical risk factors, such as fibroblast growth factor 23 (FGF23), calcium, and phosphorus. Although vitamin D sterols raise these risk markers when lowering parathyroid hormone (PTH), calcimimetics lower them. Trials demonstrate that combined approaches best 'normalize' the mineral metabolism axis in end-stage renal disease (ESRD). Observations embedded within major trials of calcimimetics reveal that adjustment of calcium-based binders and dialysate calcium is a common approach to adverse effects of these drugs with some initial, but inconclusive, evidence that these co-interventions may impact outcomes. SUMMARY The multiple, and often opposing, biochemical effects of many mineral metabolism drugs provides a strong rationale for studying integrated management strategies that consider combinations of drugs and co-interventions as a whole. This remains a current gap in the field with opportunities for clinical trials.
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Affiliation(s)
- Julia J Scialla
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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20
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Jovanovich A, Kendrick J. Personalized Management of Bone and Mineral Disorders and Precision Medicine in End-Stage Kidney Disease. Semin Nephrol 2018; 38:397-409. [PMID: 30082059 PMCID: PMC6615060 DOI: 10.1016/j.semnephrol.2018.05.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Chronic kidney disease mineral bone disorder (CKD-MBD) is common in end-stage renal disease and is associated with an increased risk of cardiovascular morbidity and mortality. Mainstays of treatment include decreasing serum phosphorus level toward the normal range with dietary interventions and phosphate binders and treating increased parathyroid hormone levels with activated vitamin D and/or calcimimetics. There is significant variation in serum levels of mineral metabolism markers, intestinal absorption of phosphorus, and therapeutic response among individual patients and subgroups of patients with end-stage renal disease. This variation may be partly explained by polymorphisms in genes associated with calcium and phosphorus homeostasis such as the calcium-sensing receptor gene, the vitamin D-binding receptor gene, and genes associated with vascular calcification. In this review, we discuss how personalized medicine may be used for the management of CKD-MBD and how it ultimately may lead to improved clinical outcomes. Although genetic variants may seem attractive targets to tailor CKD-MBD therapy, complete understanding of how these polymorphisms function and their clinical utility and applicability to personalized medicine need to be determined.
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MESH Headings
- Bone Diseases, Metabolic/etiology
- Bone Diseases, Metabolic/genetics
- Bone Diseases, Metabolic/metabolism
- Bone Diseases, Metabolic/therapy
- Calcium/metabolism
- Cardiovascular Diseases
- Humans
- Hyperparathyroidism, Secondary/etiology
- Hyperparathyroidism, Secondary/metabolism
- Hyperparathyroidism, Secondary/therapy
- Intestinal Absorption
- Kidney Failure, Chronic/complications
- Kidney Failure, Chronic/metabolism
- Kidney Failure, Chronic/therapy
- Parathyroid Hormone/metabolism
- Phosphorus/metabolism
- Polymorphism, Genetic
- Precision Medicine
- Receptors, Calcium-Sensing/genetics
- Vascular Calcification/etiology
- Vascular Calcification/metabolism
- Vitamin D/metabolism
- Vitamin D-Binding Protein/genetics
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Affiliation(s)
- Anna Jovanovich
- Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, CO.; VA Eastern Colorado Healthcare System, Denver, CO
| | - Jessica Kendrick
- Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, CO..
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21
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Leypoldt JK, Agar BU, Cheung AK, Bernardo AA. A Pseudo-One Compartment Model of Phosphorus Kinetics During Hemodialysis: Further Supporting Evidence. Artif Organs 2017; 41:1043-1048. [PMID: 29148130 DOI: 10.1111/aor.12897] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 09/13/2016] [Accepted: 11/01/2016] [Indexed: 11/29/2022]
Abstract
A pseudo-one compartment model has been proposed to describe phosphorus kinetics during hemodialysis and the immediate post-dialysis period. This model assumes that phosphorus mobilization from tissues is proportional to the difference between the pre-dialysis serum concentration (a constant) and the instantaneous serum concentration. The current study is exploratory and evaluated the ability of a pseudo-one compartment model to describe the kinetics of phosphorus during two short hemodialysis treatments separated by a 60-min inter-treatment period without dialysis; the latter is the post-dialysis rebound period for the first short hemodialysis treatment. Serum was collected frequently during both hemodialysis treatments and the inter-treatment period to assess phosphorus kinetics in 21 chronic hemodialysis patients. Phosphorus mobilization clearance and pre-dialysis central distribution volume were previously estimated for each patient during the first hemodialysis treatment and the inter-treatment period. Assuming those kinetic parameters remained constant for each patient, serum phosphorus concentrations during the second treatment were used to estimate the driving force concentration (Cdf ) for phosphorus mobilization from tissues during the second treatment. Treatment time (117 ± 14 [mean ± standard deviation] vs. 117 ± 14 min), dialyzer phosphorus clearance (151 ± 25 vs. 140 ± 32 mL/min), and net fluid removal (1.44 ± 0.74 vs. 1.47 ± 0.76 L) were similar during both short hemodialysis treatments. Measured phosphorus concentration at the start of the second hemodialysis treatment (3.3 ± 0.9 mg/dL) was lower (P < 0.001) than at the start of the first treatment or Cpre (5.4 ± 1.9 mg/dL). Calculated Cdf was 4.9 ± 2.0 mg/dL, not significantly different from Cpre (P = 0.12). Cdf and Cpre were correlated (R = 0.72, P < 0.001). The results from this study demonstrate that the driving force concentration for phosphorus mobilization during hemodialysis is constant and not different from that pre-dialysis, providing further evidence supporting a fundamental assumption of the pseudo-one compartment model.
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Affiliation(s)
| | | | - Alfred K Cheung
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
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22
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Chazot G, Lemoine S, Juillard L. [Modelling of phosphorus transfers during haemodialysis]. Nephrol Ther 2017; 13 Suppl 1:S89-S93. [PMID: 28577749 DOI: 10.1016/j.nephro.2017.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 02/13/2017] [Indexed: 12/19/2022]
Abstract
Chronic kidney disease causes hyperphosphatemia, which is associated with increased cardiovascular risk and mortality. In patients with end-stage renal disease, haemodialysis allows the control of hyperphosphatemia. During a 4-h haemodialysis session, between 600 and 700mg of phosphate are extracted from the plasma, whereas the latter contains only 90mg of inorganic phosphate. The precise origin of phosphates remains unknown. The modelling of phosphorus transfers allows to predict the outcome after changes in dialysis prescription (duration, frequency) with simple two-compartment models and to describe the transfers between the different body compartments with more complex models. Work using 31P nuclear magnetic resonance spectroscopy performed in animals showed an increase in intracellular phosphate concentration and a decrease in intracellular ATP during a haemodialysis session suggesting an intracellular origin of phosphates.
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Affiliation(s)
- Guillaume Chazot
- Service de néphrologie et exploration fonctionnelle rénale, hôpital Édouard-Herriot, hospices civils de Lyon, 5, place d'Arsonval, 69437 Lyon, France; Université Lyon 1, 43, boulevard du 11-Novembre-1918, 69100 Villeurbanne, France
| | - Sandrine Lemoine
- Service de néphrologie et exploration fonctionnelle rénale, hôpital Édouard-Herriot, hospices civils de Lyon, 5, place d'Arsonval, 69437 Lyon, France; Université Lyon 1, 43, boulevard du 11-Novembre-1918, 69100 Villeurbanne, France; Inserm U1060 OPeRa, Carmen, 59, boulevard Pinel, 69500 Bron, France
| | - Laurent Juillard
- Service de néphrologie et exploration fonctionnelle rénale, hôpital Édouard-Herriot, hospices civils de Lyon, 5, place d'Arsonval, 69437 Lyon, France; Université Lyon 1, 43, boulevard du 11-Novembre-1918, 69100 Villeurbanne, France; Inserm U1060 OPeRa, Carmen, 59, boulevard Pinel, 69500 Bron, France.
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23
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Abstract
Hemodialysis treatment time and Kt/V can both be considered to be primary measures of hemodialysis adequacy, because when either goes to zero, mortality is certain in patients without residual kidney function. Treatment time is important, but it needs to be adjusted based on surface-area-normalized Kt/V, residual kidney function, and expected ultrafiltration rate. Rescaling dose of dialysis measured as Kt/V to body surface area prevents ultrashort dialysis in small patients, women, and children with minimal residual kidney function. Most if not all of the observational studies of associations between outcome and dialysis session length are probably confounded by dose targeting bias. Once adequate Kt/V (taking into account body surface area) has been provided, adequate dialysis time probably is most relevant in terms of limiting the need for a high fluid removal rate. The latter may adversely impact survival by causing recurrent ischemia to cardiovascular and other tissues. There is little high-quality evidence at this time to support a minimum 4-hour treatment time for all patients, regardless of body size, solute removal, or residual kidney function. On the other hand, there is little evidence that prolonging weekly treatment time up to 24 hours per week is harmful. The final decision regarding treatment time is best individualized, based on patient acceptability and experience, residual kidney function, body surface-area-normalized Kt/V, and expected ultrafiltration rate.
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Affiliation(s)
- John T Daugirdas
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
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24
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Foster JD. Update on Mineral and Bone Disorders in Chronic Kidney Disease. Vet Clin North Am Small Anim Pract 2016; 46:1131-49. [PMID: 27436330 DOI: 10.1016/j.cvsm.2016.06.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The inappropriate phosphorus retention observed in chronic kidney disease is central to the pathophysiology of mineral and bone disorders observed in these patients. Subsequent derangements in serum fibroblast growth factor 23, parathyroid hormone, and calcitriol concentrations play contributory roles. Therapeutic intervention involves dietary phosphorus restriction and intestinal phosphate binders in order to correct phosphorus retention and maintain normocalcemia. Additional therapies may be considered to normalize serum fibroblast growth factor 23 and parathyroid hormone.
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Affiliation(s)
- Jonathan D Foster
- Department of Clinical Studies, University of Pennsylvania School of Veterinary Medicine, 3900 Delancey Street, Philadelphia, PA 19104, USA.
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Affiliation(s)
- John T. Daugirdas
- Department of Medicine; University of Illinois at Chicago; Chicago Illinois
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