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Ito K, Akizawa T, Arita K, Mitobe Y, Komatsu N. Effect of ferric citrate hydrate on fibroblast growth factor 23 and platelets in non-dialysis-dependent chronic kidney disease and non-chronic kidney disease patients with iron deficiency anemia. Clin Exp Nephrol 2024:10.1007/s10157-023-02455-6. [PMID: 38402503 DOI: 10.1007/s10157-023-02455-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 12/27/2023] [Indexed: 02/26/2024]
Abstract
BACKGROUND Iron deficiency anemia (IDA) increases levels of C-terminal fibroblast growth factor 23 (cFGF23) and platelet count (PLT), each of which is associated with cardiovascular events. Therefore, we hypothesized that iron replacement with ferric citrate hydrate (FC) would decrease cFGF23 levels and PLT in patients with IDA. METHODS In a randomized, open-label, multicenter, 24-week clinical trial, patients with non-dialysis-dependent chronic kidney disease (CKD) and non-CKD complicated by IDA (8.0 ≤ hemoglobin < 11.0 g/dL; and serum ferritin < 50 ng/mL [CKD]; < 12 ng/mL [non-CKD]) were randomized 1:1 to FC-low (500 mg: approximately 120 mg elemental iron/day) or FC-high (1000 mg: approximately 240 mg elemental iron/day). If sufficient iron replacement had been achieved after week 8, further treatment was discontinued. RESULTS Seventy-three patients were allocated to FC-low (CKD n = 21, non-CKD n = 15) and FC-high (CKD n = 21, non-CKD n = 16). Regardless of CKD status, FC increased serum ferritin and transferrin saturation, did not change intact FGF23 or serum phosphorus, but decreased cFGF23. In FC-low group, median changes in cFGF23 from baseline to week 8 were -58.00 RU/mL in CKD and -725.00 RU/mL in non-CKD; in FC-high group, the median changes were -66.00 RU/mL in CKD and -649.50 RU/mL in non-CKD. By week 8, FC treatment normalized PLT in all patients with high PLT at baseline (>35.2 × 104/µL; FC-low: 1 CKD, 8 non-CKD; FC-high: 3 CKD, 8 non-CKD). CONCLUSION Regardless of CKD status, iron replacement with FC decreased elevated cFGF23 levels and normalized elevated PLT in patients with IDA. CLINICAL TRIAL REGISTRATION NUMBER jRCT2080223943.
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Affiliation(s)
- Kyoko Ito
- Medical Affairs Department, Torii Pharmaceutical Co., Ltd., 3-4-1, Nihonbashi-Honcho, Chuo-Ku, Tokyo, 103-8439, Japan
- Doctoral Program in Life Science Innovation (Disease Mechanism), Degree Programs in Comprehensive Human Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8577, Japan
| | - Tadao Akizawa
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Namics Shinagawa 301, 4-24-51 Takanawa, Minato-Ku, Tokyo, 108-0074, Japan.
| | - Kojo Arita
- Clinical Development Department, Pharmaceutical Division, Japan Tobacco Inc., 3-4-1, Nihonbashi-Honcho, Chuo-Ku, Tokyo, 103-0023, Japan
| | - Yuko Mitobe
- Medical Affairs Department, Torii Pharmaceutical Co., Ltd., 3-4-1, Nihonbashi-Honcho, Chuo-Ku, Tokyo, 103-8439, Japan
| | - Norio Komatsu
- Department of Hematology, Juntendo University School of Medicine, 2-1-1, Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
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Ariceta G, Beck-Nielsen SS, Boot AM, Brandi ML, Briot K, de Lucas Collantes C, Emma F, Giannini S, Haffner D, Keen R, Levtchenko E, Mӓkitie O, Mughal MZ, Nilsson O, Schnabel D, Tripto-Shkolnik L, Liu J, Williams A, Wood S, Zillikens MC. The International X-Linked Hypophosphatemia (XLH) Registry: first interim analysis of baseline demographic, genetic and clinical data. Orphanet J Rare Dis 2023; 18:304. [PMID: 37752558 PMCID: PMC10523658 DOI: 10.1186/s13023-023-02882-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 08/24/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND X-linked hypophosphatemia (XLH) is a rare, hereditary, progressive, renal phosphate-wasting disorder characterized by a pathological increase in FGF23 concentration and activity. Due to its rarity, diagnosis may be delayed, which can adversely affect outcomes. As a chronic disease resulting in progressive accumulation of musculoskeletal manifestations, it is important to understand the natural history of XLH over the patient's lifetime and the impact of drug treatments and other interventions. This multicentre, international patient registry (International XLH Registry) was established to address the paucity of these data. Here we present the findings of the first interim analysis of the registry. RESULTS The International XLH Registry was initiated in August 2017 and includes participants of all ages diagnosed with XLH, regardless of their treatment and management. At the database lock for this first interim analysis (29 March 2021), 579 participants had entered the registry before 30 November 2020 and are included in the analysis (360 children [62.2%], 217 adults [37.5%] and 2 whose ages were not recorded [0.3%]; 64.2% were female). Family history data were available for 319/345 (92.5%) children and 145/187 (77.5%) adults; 62.1% had biological parents affected by XLH. Genetic testing data were available for 341 (94.7%) children and 203 (93.5%) adults; 370/546 (67.8%) had genetic test results; 331/370 (89.5%) had a confirmed PHEX mutation. A notably longer time to diagnosis was observed in adults ≥ 50 years of age (mean [median] duration 9.4 [2.0] years) versus all adults (3.7 [0.1] years) and children (1.0 [0.2] years). Participants presented with normal weight, shorter length or height and elevated body mass index (approximately - 2 and + 2 Z-scores, respectively) versus the general population. Clinical histories were collected for 349 participants (239 children and 110 adults). General data trends for prevalence of bone, dental, renal and joint conditions in all participants were aligned with expectations for a typical population of people with XLH. CONCLUSION The data collected within the International XLH Registry, the largest XLH registry to date, provide substantial information to address the paucity of natural history data, starting with demographic, family history, genetic testing, diagnosis, auxology and baseline data on clinical presentation.
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Affiliation(s)
- Gema Ariceta
- Department of Pediatric Nephrology, Hospital Vall d'Hebron, Universitat Autonoma Barcelona, Barcelona, Spain.
| | - Signe Sparre Beck-Nielsen
- Centre for Rare Diseases, Aarhus University Hospital, Åarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Åarhus, Denmark
| | - Annemieke M Boot
- Department of Pediatrics, Division of Endocrinology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Karine Briot
- Hôpital Cochin, Service de Rhumatologie, Centre de Référence des Maladies Rares du Métabolisme du Calcium et du Phosphate Filière OSCAR, AP-HP, Paris, France
| | | | - Francesco Emma
- Division of Nephrology, Bambino Gesù Children's Hospital - IRCCS, Rome, Italy
| | - Sandro Giannini
- Department of Medicine, Clinica Medica 1, University of Padova, Padua, Italy
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Richard Keen
- Royal National Orthopaedic Hospital, Stanmore, UK
| | - Elena Levtchenko
- Department of Pediatric Nephrology and Development and Regeneration, University Hospitals Leuven, University of Leuven, Leuven, Belgium
| | - Outi Mӓkitie
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - M Zulf Mughal
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester University Hospital's NHS Trust, Manchester, UK
| | - Ola Nilsson
- Division of Pediatric Endocrinology and Center for Molecular Medicine, Department of Women's and Children's Health, Karolinska Institutet and University Hospital, Stockholm, Sweden
- School of Medical Sciences and Department of Pediatrics, Örebro University and University Hospital, Örebro, Sweden
| | - Dirk Schnabel
- Center for Chronically Sick Children, Pediatric Endocrinology, Charité, University Medicine Berlin, Berlin, Germany
| | - Liana Tripto-Shkolnik
- Division of Endocrinology, Diabetes and Metabolism, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | | | - Sue Wood
- Kyowa Kirin International, Marlow, UK
| | - M Carola Zillikens
- Bone Center, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Meyer MB, Pike JW. Genomic mechanisms controlling renal vitamin D metabolism. J Steroid Biochem Mol Biol 2023; 228:106252. [PMID: 36657729 PMCID: PMC10006327 DOI: 10.1016/j.jsbmb.2023.106252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 01/15/2023] [Indexed: 01/18/2023]
Abstract
Vitamin D metabolism centers on regulation in the kidney of CYP27B1 induction by PTH, suppression by FGF23 and 1,25(OH)2D3, and reciprocal CYP24A1 suppression by PTH, and induction by FGF23 and 1,25(OH)2D3. This coordinated genomic regulation through enhancer modules results in the production and dynamic maintenance of circulating endocrine 1,25(OH)2D3 which, together with PTH and FGF23, controls mineral homeostasis. We discovered enhancers near Cyp27b1 in the mouse kidney located within intronic regions of Mettl1 and Mettl21b genes. These kidney-specific enhancers ("M1", "M21") control Cyp27b1. Through CRISPR/Cas deletion, we found that PTH activation of Cyp27b1 is lost with deletion of M1, whereas FGF23 suppression is lost with deletion of M21. The combination of both deletions (M1/M21-DIKO) eliminated the suppression by 1,25(OH)2D3. Cyp24a1 activation by 1,25(OH)2D3 is controlled by a promoter proximal pair of VDREs as well as a distal region - 35 to - 37 kb (DS2). We also found that FGF23 activation and PTH suppression of Cyp24a1 was located in a region - 21 to - 37 kb downstream (DS1). More recently, using in vivo ChIP-seq in mouse kidney, we demonstrate that PTH activation rapidly induces increased recruitment of pCREB and its coactivators, CBP and CRTC2, to the M1 and M21 enhancers near the Cyp27b1 gene. At distal enhancers of the Cyp24a1 gene, PTH suppression promotes dismisses CBP with only minor changes in pCREB and CRTC2 occupancy, all of which correlate with a suppression of basal histone acetylation across this locus and reduced transcripts. Surprisingly, we find that 1,25(OH)2D3 suppression increases the occupancy of CRTC2 in the M1 enhancer, a novel observation for CRTC2 and/or 1,25(OH)2D3 action. The suppressive actions of 1,25(OH)2D3 and FGF23 at the Cyp27b1 gene are associated with a reduction in CBP recruitment at these enhancers. Although FGF23-regulated transcription factors remain unknown, we hypothesize that VDR occupancy induced at the M1 and M21 enhancers by 1,25(OH)2D3 likely disrupts or competes with the active conformation of these CREB modules thereby preventing full induction by PTH. Our findings show coactivators such as CRTC2 and CBP contribute to Cyp27b1 and Cyp24a1 transcription and provide molecular insight into the coordinated mechanistic actions of PTH, FGF23, and 1,25(OH)2D3 in the kidney that regulate mineral homeostasis.
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Affiliation(s)
- Mark B Meyer
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, WI 53706, USA; Department of Biochemistry, University of Wisconsin-Madison, Madison, WI 53706, USA.
| | - J Wesley Pike
- Department of Biochemistry, University of Wisconsin-Madison, Madison, WI 53706, USA
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Toi N, Imanishi Y, Nagata Y, Kurajoh M, Morioka T, Shoji T, Shinto Y, Emoto M. Improvement in the mobility of a patient with fibroblast growth factor 23-related hypophosphatemic osteomalacia and decompensated liver cirrhosis in response to burosumab: a case report. Endocr J 2022; 70:419-426. [PMID: 36575021 DOI: 10.1507/endocrj.ej22-0520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Acquired fibroblast growth factor (FGF) 23-related hypophosphatemic osteomalacia is characterized clinically by muscle weakness, bone pain, and fractures. Its biochemical features include hypophosphatemia, caused by renal phosphate wasting, and inappropriately normal or low 1,25-dihydroxy-vitamin D levels. Recently, burosumab, a fully human monoclonal antibody targeting FGF23, was approved for the treatment of FGF23-related hypophosphatemic rickets and osteomalacia. We report the case of a 75-year-old Japanese woman with decompensated liver cirrhosis and hepatic encephalopathy, caused by primary biliary cholangitis, who complained of back pain and limited mobility resulting from multiple vertebral fractures. She was not receiving iron infusion therapy and denied alcohol consumption. The patient exhibited hypophosphatemia with a low tubular maximum reabsorption of phosphate per unit glomerular filtration rate (TmP/GFR) and a high circulating concentration of FGF23. Conventional therapy with alfacalcidol and oral phosphate slightly improved her serum phosphate concentration and back pain, but she experienced a hip fracture, causing her to become wheelchair-dependent. Burosumab was initiated 8 weeks after the hip fracture, which increased her serum phosphate concentration and TmP/GFR. Her mobility gradually improved, such that she could walk without a cane after 16 weeks of treatment. Her lumbar bone mineral density increased after 48 weeks. Hepatic encephalopathy developed once before the initiation of treatment and twice after the initiation of the therapy, but her liver function was preserved. This is the first study to report the efficacy and safety of burosumab treatment for FGF23-related hypophosphatemic osteomalacia with decompensated liver cirrhosis.
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Affiliation(s)
- Norikazu Toi
- Department of Metabolism, Endocrinology, and Molecular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Yasuo Imanishi
- Department of Metabolism, Endocrinology, and Molecular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Yuki Nagata
- Department of Vascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Masafumi Kurajoh
- Department of Metabolism, Endocrinology, and Molecular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Tomoaki Morioka
- Department of Metabolism, Endocrinology, and Molecular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Tetsuo Shoji
- Department of Vascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Yoshitaka Shinto
- Shinto Orthopedics and Rheumatology Clinic, Osaka 545-0052, Japan
| | - Masanori Emoto
- Department of Metabolism, Endocrinology, and Molecular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8585, Japan
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Ishihara Y, Ohata Y, Takeyari S, Kitaoka T, Fujiwara M, Nakano Y, Yamamoto K, Yamada C, Yamamoto K, Michigami T, Mabe H, Yamaguchi T, Matsui K, Tamada I, Namba N, Yamamoto A, Etoh J, Kawaguchi A, Kosugi R, Ozono K, Kubota T. Genotype-phenotype analysis, and assessment of the importance of the zinc-binding site in PHEX in Japanese patients with X-linked hypophosphatemic rickets using 3D structure modeling. Bone 2021; 153:116135. [PMID: 34333162 DOI: 10.1016/j.bone.2021.116135] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 07/09/2021] [Accepted: 07/26/2021] [Indexed: 11/25/2022]
Abstract
X-linked hypophosphatemic rickets (XLH) is an inheritable type of rickets caused by inactivating variants in the phosphate regulating endopeptidase homolog X-linked (PHEX) gene, which results in the overproduction of fibroblast growth factor 23 (FGF23). The mechanism by which PHEX impairment leads to FGF23 overproduction is unknown. Because little is known regarding the genotype-phenotype correlation in Japanese XLH, we summarized the available clinical and genetic data and analyzed the genotype-phenotype relationships using 3-dimensional (3D) structure modeling to clarify the XLH pathophysiology. We retrospectively reviewed the clinical features and performed genetic analysis of 39 Japanese patients with XLH from 28 unrelated pedigrees carrying any known or novel PHEX variant. To predict changes in the 3D structure of mutant PHEX, we constructed a putative 3D model of each mutant and evaluated the effect of structural alteration by genotype-phenotype correlation analysis. Genetic analysis revealed 23 PHEX variants, including eight novel variants. They were associated with high i-FGF23 levels, hypophosphatemia, phosphaturia, high alkaline phosphatase levels, and short stature. No gene dosage effect or genotype-phenotype correlation was observed when truncating and non-truncating variants were compared. However, the conservation of the zinc-binding site and cavity in PHEX had an impact on the elevation of i-FGF23 levels. Via genotype-phenotype relationship analysis using 3D modeling, we showed that the zinc-binding site and cavity in PHEX can play a critical role in its function. These findings provide new genetic clues for investigating the function of PHEX and the pathogenesis of XLH.
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Affiliation(s)
- Yasuki Ishihara
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Japan; The 1st. Department of Oral and Maxillofacial Surgery, Osaka University Graduate School of Dentistry, Suita, Japan; Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yasuhisa Ohata
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Japan
| | - Shinji Takeyari
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Japan
| | - Taichi Kitaoka
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Japan
| | - Makoto Fujiwara
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Japan; The 1st. Department of Oral and Maxillofacial Surgery, Osaka University Graduate School of Dentistry, Suita, Japan
| | - Yukako Nakano
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Japan
| | - Kenichi Yamamoto
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Japan; Department of Statistical Genetics, Osaka University Graduate School of Medicine, Suita, Japan
| | - Chieko Yamada
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Japan
| | - Katsusuke Yamamoto
- Department of Pediatric Nephrology and Metabolism, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Toshimi Michigami
- Department of Bone and Mineral Research, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Hiroyo Mabe
- Department of Pediatrics, Kumamoto University Hospital, Kumamoto, Japan
| | - Takeshi Yamaguchi
- Department of Pediatrics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Katsuyuki Matsui
- Department of Pediatrics, Shiga University of Medical Science, Otsu, Japan
| | - Izumi Tamada
- Department of Pediatrics, Imakiire General Hospital, Kagoshima, Japan
| | - Noriyuki Namba
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Japan; Division of Pediatrics and Perinatology, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Akiko Yamamoto
- Department of Pediatrics, Kumamoto Chuo Hospital, Kumamoto, Japan
| | - Junya Etoh
- Department of Pediatrics, Saga-Ken Medical Centre Koseikan, Saga, Japan
| | - Azusa Kawaguchi
- Department of Pediatrics, National Hospital Organization Hokkaido Medical Center, Sapporo, Japan
| | - Rieko Kosugi
- Department of Diabetes and Endocrinology, Shizuoka General Hospital, Shizuoka, Japan
| | - Keiichi Ozono
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Japan
| | - Takuo Kubota
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Japan.
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Zhao SJ, Wang ZX, Chen L, Wang FX, Kong LD. Effect of different phosphate binders on fibroblast growth factor 23 levels in patients with chronic kidney disease: a systematic review and meta-analysis of randomized controlled trials. Ann Palliat Med 2021; 11:1264-1277. [PMID: 34775773 DOI: 10.21037/apm-21-1943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/15/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Serum intact fibroblast growth factor 23 (FGF23) levels are progressively increased in relation to the severity of kidney dysfunction. High serum intact FGF23 concentration is associated with the increased cardiovascular morbidity and mortality in patients with chronic kidney disease (CKD). Clinically, phosphate binders are commonly used to reduce serum intact FGF23 levels in CKD patients by lowering serum phosphate levels. It is not clear whether all kinds of phosphate binders can reduce serum intact FGF23 levels, or which kind of phosphate binders is more effective in reducing serum intact FGF23 levels in patients with CKD. The aim of this systematic review and meta-analysis was to compare the efficiency of different kinds of commonly used phosphate binders on serum intact FGF23 levels in patients with CKD. METHODS Systematic searches were performed through PubMed, Cochrane Central Register of Controlled Trials and Embase from 1999 to 2020. We included the studies performed only in human subjects. All randomized clinical trials (RCTs) were included. Reviews, case reports, letters, commentaries, abstracts and unpublished articles were excluded. Risk of bias was assessed by the Cochrane Collaboration's tool. Random effect was performed in meta-analysis. Meta-regression was used to investigate heterogeneity. RESULTS Of 1,895 articles, 15 RCTs (comprising 1,098 participants) were included. Common sources of bias were selection bias. Phosphate binders could reduce serum intact FGF23 levels in patients with CKD [standard mean difference (SMD) of total change in serum intact FGF23 levels was 0.91 PG/mL (95% confidence interval: 0.38 to 1.44 PG/mL]. Meta-regression explained 89.02% of heterogeneous sources, indicating that dietary phosphate intake could weaken the effect of phosphate binders on reducing serum intact FGF23 levels, and the effect of phosphate binders on reducing serum intact FGF23 levels in dialysis patients was better than that in early-to-middle CKD patients. DISCUSSION Phosphate binders can effectively reduce serum intact FGF23 levels in CKD patients, and iron-based phosphate binders have better effect on reducing serum intact FGF23 levels than other phosphate binders.
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Affiliation(s)
- Si-Jie Zhao
- School of Life Sciences, Nanjing University, Nanjing, China
| | - Zi-Xuan Wang
- School of Life Sciences, Nanjing University, Nanjing, China
| | - Li Chen
- School of Life Sciences, Nanjing University, Nanjing, China
| | - Fei-Xuan Wang
- Nanjing Institute of Product Quality Inspection, Nanjing, China
| | - Ling-Dong Kong
- School of Life Sciences, Nanjing University, Nanjing, China
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Papadopoulou A, Bountouvi E, Karachaliou FE. The Molecular Basis of Calcium and Phosphorus Inherited Metabolic Disorders. Genes (Basel) 2021; 12:genes12050734. [PMID: 34068220 PMCID: PMC8153134 DOI: 10.3390/genes12050734] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 04/30/2021] [Accepted: 05/05/2021] [Indexed: 02/07/2023] Open
Abstract
Calcium (Ca) and Phosphorus (P) hold a leading part in many skeletal and extra-skeletal biological processes. Their tight normal range in serum mirrors their critical role in human well-being. The signalling “voyage” starts at Calcium Sensing Receptor (CaSR) localized on the surface of the parathyroid glands, which captures the “oscillations” of extracellular ionized Ca and transfers the signal downstream. Parathyroid hormone (PTH), Vitamin D, Fibroblast Growth Factor (FGF23) and other receptors or ion-transporters, work synergistically and establish a highly regulated signalling circuit between the bone, kidneys, and intestine to ensure the maintenance of Ca and P homeostasis. Any deviation from this well-orchestrated scheme may result in mild or severe pathologies expressed by biochemical and/or clinical features. Inherited disorders of Ca and P metabolism are rare. However, delayed diagnosis or misdiagnosis may cost patient’s quality of life or even life expectancy. Unravelling the thread of the molecular pathways involving Ca and P signaling, we can better understand the link between genetic alterations and biochemical and/or clinical phenotypes and help in diagnosis and early therapeutic intervention.
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Schoeb M, Räss A, Frei N, Aczél S, Brändle M, Bilz S. High Risk of Hypophosphatemia in Patients with Previous Bariatric Surgery Receiving Ferric Carboxymaltose: A Prospective Cohort Study. Obes Surg 2020; 30:2659-2666. [PMID: 32221822 DOI: 10.1007/s11695-020-04544-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Iron deficiency is a common finding in patients with previous bariatric surgery, and parenteral supplementation is frequently required. Ferric carboxymaltose (FCM) is among the preferred compounds used but may be associated with new-onset hypophosphatemia. This study was undertaken to study the prevalence of hypophosphatemia following FCM in patients with previous bariatric surgery, a population that may be at particular risk due to highly prevalent secondary hyperparathyroidism. METHODS Patients with previous bariatric surgery and iron depletion scheduled for FCM infusion were prospectively studied before and one week after FCM application. The primary endpoint was new-onset hypophosphatemia. Patients were followed until plasma phosphate had normalized without replacement. RESULTS Fifty-two patients (40 females) following Roux-en-Y gastric bypass (n = 50) or sleeve gastrectomy (n = 2), with a median age of 46 years (range 22-68) and a BMI of 32.2 kg/m2 (27.5-37.3), were analyzed. Fifteen patients (29%) developed new-onset hypophosphatemia, with 11 (21%) requiring oral phosphate supplementation for a median duration of 14 days (14-25). The plasma phosphate decreased by 0.3 mmol/l (-0.5--0.2; p < 0.001) secondary to a 56% increase in the fractional urinary phosphate excretion (p < 0.001). This was associated with a significant increase in serum intact FGF23 (+30%; p < 0.001) and a decrease in serum 1,25(OH)2 vitamin D3 concentrations (-37.6%; p < 0.001). CONCLUSION Patients with previous bariatric surgery receiving FCM are at considerable risk of developing significant hypophosphatemia secondary to increased renal phosphate wasting through a mechanism involving FGF23. Monitoring plasma phosphate should be considered following FCM in patients with previous bariatric surgery. CLINICAL TRIAL REGISTRATION ISRCTN registry, ISRCTN12291677, https://www.isrctn.com.
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Affiliation(s)
- Manuela Schoeb
- Division of Endocrinology and Diabetes, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland.
| | - Andrea Räss
- Division of Endocrinology and Diabetes, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
| | - Nicola Frei
- Division of General Internal Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Stefan Aczél
- Division of Endocrinology and Diabetes, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
| | - Michael Brändle
- Division of Endocrinology and Diabetes, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
- Division of General Internal Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Stefan Bilz
- Division of Endocrinology and Diabetes, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
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Meyer MB, Pike JW. Mechanistic homeostasis of vitamin D metabolism in the kidney through reciprocal modulation of Cyp27b1 and Cyp24a1 expression. J Steroid Biochem Mol Biol 2020; 196:105500. [PMID: 31629064 PMCID: PMC6954286 DOI: 10.1016/j.jsbmb.2019.105500] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 10/07/2019] [Accepted: 10/14/2019] [Indexed: 01/08/2023]
Abstract
Cyp27b1 and Cyp24a1 are reciprocally regulated in the kidney by the key hormones PTH, FGF23, and 1,25(OH)2D3. Our recent genomic studies in mice identified a complex kidney-specific enhancer module located within the introns of adjacent Mettl1 (M1) and Mettl21b (M21) genes that mediate basal and PTH induction of Cyp27b1 as well as suppression by FGF23 and 1,25(OH)2D3. Gross deletion of these segments in mice has severe consequences on skeletal health, and directly affects Cyp27b1 expression in the kidney. Deletion of both M1 and M21 submodules together fully eliminates basal Cyp27b1 expression in the kidney, leading to a systemic and skeletal phenotype similar to that of the Cyp27b1-KO mouse due to depletion of 1,25(OH)2D3 and high PTH. Cyp24a1 levels in the double KO mouse were low due to compensatory regulation by elevated PTH and reduced FGF23. However, expression of Cyp27b1 and retention of its regulation by inflammation (LPS) in the NRTCs remained unperturbed. Dietary normalization of calcium, phosphate, PTH, and FGF23 rescues this aberrant phenotype and normalizes the skeletal issues. Cyp24a1 is controlled by its own unique enhancers for 1,25(OH)2D3, FGF23, and PTH. We were also able to eliminate these activities in mice. Collectively, the hormone-mediated enhancer regulation of both Cyp27b1 and Cyp24a1 in the kidney is responsible for the circulating levels of 1,25(OH)2D3 in the blood which in turn primarily affects calcium and phosphate regulation. Importantly, we can now manipulate this system with our enhancer deletion animal models to study 1,25(OH)2D3 production in non-renal target cells and tissues not only in disease, where it is known to affect the immune system, but also in healthy individuals. Here we will review our studies that have defined a finely balanced homeostatic control mechanism employed by PTH and FGF23 with catastrophic toxicity protection from 1,25(OH)2D3 in the genomic regulation of vitamin D metabolism and its accompanied control of mineral maintenance.
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Affiliation(s)
- Mark B Meyer
- Department of Biochemistry, University of Wisconsin-Madison, Madison, WI, 53706, USA.
| | - J Wesley Pike
- Department of Biochemistry, University of Wisconsin-Madison, Madison, WI, 53706, USA
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10
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Edmonston D, Wojdyla D, Mehta R, Cai X, Lora C, Cohen D, Townsend RR, He J, Go AS, Kusek J, Weir MR, Isakova T, Pencina M, Wolf M. Single Measurements of Carboxy-Terminal Fibroblast Growth Factor 23 and Clinical Risk Prediction of Adverse Outcomes in CKD. Am J Kidney Dis 2019; 74:771-781. [PMID: 31445926 DOI: 10.1053/j.ajkd.2019.05.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 05/13/2019] [Indexed: 01/02/2023]
Abstract
RATIONALE & OBJECTIVE An elevated fibroblast growth factor 23 (FGF-23) level is independently associated with adverse outcomes in populations with chronic kidney disease, but it is unknown whether FGF-23 testing can improve clinical risk prediction in individuals. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS Participants in the Chronic Renal Insufficiency Cohort (CRIC) Study (n = 3,789). EXPOSURE Baseline carboxy-terminal FGF-23 (cFGF-23) level. OUTCOMES All-cause and cardiovascular (CV) mortality, incident end-stage renal disease (ESRD), heart failure (HF) admission, and atherosclerotic events at 3, 5, and 8 years. ANALYTICAL APPROACH We assessed changes in model performance by change in area under the receiver operating characteristic curve (ΔAUC), integrated discrimination improvement (IDI), relative IDI, and net reclassification index (NRI) above standard clinical factors. We performed sensitivity analyses, including an additional model comparing the addition of phosphate rather than cFGF-23 level and repeating our analyses using an internal cross-validation cohort. RESULTS Addition of a single baseline value of cFGF-23 to a base prediction model improved prediction of all-cause mortality (ΔAUC, 0.017 [95% CI, 0.001-0.033]; IDI, 0.021 [95% CI, 0.006-0.036]; relative IDI, 32.7% [95% CI, 8.5%-56.9%]), and HF admission (ΔAUC, 0.008 [95% CI, 0.0004-0.016]; IDI, 0.019 [95% CI, 0.004-0.034]; relative IDI, 10.0% [95% CI, 1.8%-18.3%]), but not CV mortality, ESRD, or atherosclerotic events at 3 years of follow-up. The NRI did not reach statistical significance for any of the 3-year outcomes. The incremental predictive utility of cFGF-23 level diminished in analyses of the 5- and 8-year outcomes. The cFGF-23 models outperformed the phosphate model for each outcome. LIMITATIONS Power to detect increased CV mortality likely limited by low event rate. The NRI is not generalizable without accepted prespecified risk thresholds. CONCLUSIONS Among individuals with CKD, single measurements of cFGF-23 improve prediction of risks for all-cause mortality and HF admission but not CV mortality, ESRD, or atherosclerotic events. Future studies should evaluate the predictive utility of repeated cFGF-23 testing.
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Affiliation(s)
- Daniel Edmonston
- Division of Nephrology, Department of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Daniel Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Rupal Mehta
- Division of Nephrology and Hypertension, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Xuan Cai
- Division of Nephrology and Hypertension, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Claudia Lora
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Debbie Cohen
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Raymond R Townsend
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jiang He
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA
| | - Alan S Go
- Kaiser Permanente Northern California Division of Research, Oakland, CA
| | | | - Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Tamara Isakova
- Division of Nephrology and Hypertension, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Michael Pencina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Myles Wolf
- Division of Nephrology, Department of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
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11
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Kinoshita Y, Takashi Y, Ito N, Ikegawa S, Mano H, Ushiku T, Fukayama M, Nangaku M, Fukumoto S. Ectopic expression of Klotho in fibroblast growth factor 23 (FGF23)-producing tumors that cause tumor-induced rickets/osteomalacia (TIO). Bone Rep 2019; 10:100192. [PMID: 30627598 DOI: 10.1016/j.bonr.2018.100192] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/28/2018] [Accepted: 12/27/2018] [Indexed: 02/03/2023] Open
Abstract
Tumor-induced rickets/osteomalacia (TIO) is a rare paraneoplastic syndrome caused by tumors that ectopically express fibroblast growth factor 23 (FGF23). FGF23 is a bone-derived hormone that regulates serum phosphate concentrations. Patients with TIO develop hypophosphatemic rickets/osteomalacia due to FGF23 excess and suffer from symptoms such as leg deformities, bone pain, skeletal muscle myopathy, and multiple fractures/pseudofractures. Usually, successful surgical removal of the causative tumors normalizes serum FGF23 and phosphate concentrations in patients with TIO. Most FGF23-producing tumors associated with TIO are histologically called phosphaturic mesenchymal tumor, mixed connective tissue variant (PMTMCT). The precise mechanism by which these tumors ectopically overproduce FGF23 outside of bone is yet to be clarified. Therefore, we performed an RNA sequencing analysis of a PMTMCT that was found in the left parotid gland of a patient with TIO. Among the upregulated genes, we focused on Klotho, the protein product of which is a single pass transmembrane protein that works along with an FGF receptor 1c as a receptor complex for FGF23. Subsequent histological analysis confirmed the ectopic expression of Klotho in other PMTMCTs. From these results, we assume that the ectopic expression of Klotho in PTMMCTs enables a positive feedback loop in FGF23 production via the activation of FGF receptor 1c and exacerbates disease manifestations in TIO. Klotho is ectopically expressed in the FGF23-producing mesenchymal tumors. Klotho enables the activation of the FGFR signaling pathway in PMTMCTs. Klotho enables the autocrine/paracrine effects of FGF23 in PMTMCTs.
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12
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Chakhtoura M, Ramnitz MS, Khoury N, Nemer G, Shabb N, Abchee A, Berberi A, Hourani M, Collins M, Ichikawa S, El Hajj Fuleihan G. Hyperphosphatemic familial tumoral calcinosis secondary to fibroblast growth factor 23 (FGF23) mutation: a report of two affected families and review of the literature. Osteoporos Int 2018; 29:1987-2009. [PMID: 29923062 DOI: 10.1007/s00198-018-4574-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 05/14/2018] [Indexed: 01/20/2023]
Abstract
Hyperphosphatemic familial tumoral calcinosis (HFTC), secondary to fibroblast growth factor 23 (FGF23) gene mutation, is a rare genetic disorder characterized by recurrent calcified masses. We describe young Lebanese cousins presenting with HFTC, based on a retrospective chart review and a prospective case study. In addition, we present a comprehensive review on the topic, based on a literature search conducted in PubMed and Google Scholar, in 2014 and updated in December 2017. While the patients had the same previously reported FGF23 gene mutation (homozygous c.G367T variant in exon 3 leading to a missense mutation), they presented with variable severity and age of disease onset (at 4 years in patient 1 and at 23 years in patient 2). A review of the literature revealed several potential patho-physiologic pathways of HFTC clinical manifestations, some of which may be independent of hyperphosphatemia. Most available treatment options aim at reducing serum phosphate level, by stimulating renal excretion or by inhibiting intestinal absorption. HFTC is a challenging disease. While the available medical treatment has a limited and inconsistent effect on disease symptomatology, surgical resection of calcified masses remains the last resort. Research is needed to determine the safety and efficacy of FGF23 replacement or molecular therapy, targeting the specific genetic aberration. Hyperphosphatemic familial tumoral calcinosis is a rare genetic disorder characterized by recurrent calcified masses, in addition to other visceral, skeletal, and vascular manifestations. It remains a very challenging disease.
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Affiliation(s)
- M Chakhtoura
- Calcium Metabolism and Osteoporosis Program, WHO Collaborating Center for Metabolic Bone Disorders, American University of Beirut Medical Center, Beirut, Lebanon.
| | - M S Ramnitz
- Section on Skeletal Disorders and Mineral Homeostasis, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - N Khoury
- Department of Radiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - G Nemer
- Department of Biochemistry and Molecular Genetics, American University of Beirut Medical Center, Beirut, Lebanon
| | - N Shabb
- Department of Pathology and Laboratory Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - A Abchee
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - A Berberi
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - M Hourani
- Department of Radiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - M Collins
- Section on Skeletal Disorders and Mineral Homeostasis, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - S Ichikawa
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - G El Hajj Fuleihan
- Calcium Metabolism and Osteoporosis Program, WHO Collaborating Center for Metabolic Bone Disorders, American University of Beirut Medical Center, Beirut, Lebanon
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13
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Takahashi H, Ozeki M, Fujisaka T, Morita H, Fujita SI, Takeda Y, Shibata K, Sohmiya K, Hoshiga M, Tamaki J, Ishizaka N. Changes in Serum Fibroblast Growth Factor 23 in Patients With Acute Myocardial Infarction. Circ J 2017; 82:767-774. [PMID: 29151454 DOI: 10.1253/circj.cj-17-0826] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Fibroblast growth factor 23 (FGF23) induces cardiac remodeling. We investigated the changes in serum FGF23 levels in patients diagnosed with acute myocardial infarction (AMI).Methods and Results:A total of 44 patients diagnosed with AMI were included in the current study. All patients underwent emergency percutaneous coronary intervention (PCI). The median of peak creatine kinase (CK) and CKMB values was 1,816 U/L and 159 U/L, respectively. Serum levels of FGF23, calcium, and inorganic phosphate (iP) were measured before PCI, and on days 1, 3, 5, 7 after PCI. Serum FGF23 levels showed a slight, but significant decrease on days 1 and 3 after PCI, and a 1.5- and 2.0-fold increase on days 5 and 7, respectively, after PCI. As compared with propensity score-matched patients without AMI, serum FGF23 was significantly lower among the current cohort of AMI patients. In 22 subjects who underwent a follow-up echocardiographic examination at 6 months after the onset of AMI, the log-transformed relative increase in FGF23 on day 7 significantly and negatively correlated with changes between LVEF on admission and that at 6 months afterward. CONCLUSIONS After a slight decrease on days 1 and 3 after admission, serum FGF23 increased significantly on days 5 and 7. The underlying mechanism and potential clinical importance of these observations require further investigation.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Junko Tamaki
- Department of Hygiene and Public Health, Osaka Medical College
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14
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Cernaro V, Lucisano S, Canale V, Bruzzese A, Caccamo D, Costantino G, Buemi M, Santoro D. Acetate-free biofiltration to remove fibroblast growth factor 23 in hemodialysis patients: a pilot study. J Nephrol 2017; 31:429-433. [PMID: 28401422 DOI: 10.1007/s40620-017-0393-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 03/23/2017] [Indexed: 12/17/2022]
Abstract
AIM Serum levels of 32 kDa-phosphaturic hormone fibroblast growth factor 23 (FGF23) rise early in renal failure in order to keep phosphatemia within the normal range; however, this compensatory mechanism itself contributes to chronic kidney disease-mineral bone disorder. High FGF23 is also associated to left ventricular hypertrophy, vascular calcifications and thus increased cardiovascular risk. The aim of this pilot pre-post study was to evaluate the effects of a single hemodiafiltration session with acetate-free biofiltration (AFB) on FGF23 serum levels. METHODS Nine hemodialysis patients were enrolled; sessions were performed using the Integra® monitor (Hospal, Bologna, Italy) and a polyacrylonitrile membrane. Peripheral venous blood samples were taken before (pre-HD), at mid- and after treatment (post-HD); dialysate samples were collected by the Quantiscan™ monitoring system. FGF23 was measured by a human FGF-23 ELISA kit. Mid- and post-HD values were corrected for hemoconcentration. RESULTS Pre-HD FGF23 levels positively correlated with dialysis vintage (r = 0.7192; p = 0.0443). They were significantly reduced by the hemodialysis session (from 2.38 ± 1.80 to 1.15 ± 1.21 ng/ml, p = 0.0171) with a reduction ratio of 52.55 ± 28.76%. FGF23 was detected in the dialysate samples. CONCLUSION FGF23 underwent a significant reduction during AFB. Such removal was greater than that induced by conventional hemodialysis as reported in the literature (19%-decrease using modified cellulosic membranes). This difference may be attributed to the ability of AFB hemodiafiltration to efficiently remove middle molecules by convection. Whether a better clearance of FGF23 during hemodialysis may result in improved cardiovascular outcomes in the long term needs to be confirmed by randomized controlled trials.
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Affiliation(s)
- Valeria Cernaro
- Department of Clinical and Experimental Medicine, University of Messina, AOU G. Martino PAD C, Via Consolare Valeria, 98100, Messina, Italy
| | - Silvia Lucisano
- Department of Clinical and Experimental Medicine, University of Messina, AOU G. Martino PAD C, Via Consolare Valeria, 98100, Messina, Italy
| | - Valeria Canale
- Department of Clinical and Experimental Medicine, University of Messina, AOU G. Martino PAD C, Via Consolare Valeria, 98100, Messina, Italy
| | - Annamaria Bruzzese
- Department of Clinical and Experimental Medicine, University of Messina, AOU G. Martino PAD C, Via Consolare Valeria, 98100, Messina, Italy
| | - Daniela Caccamo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Messina, Italy
| | - Giuseppe Costantino
- Department of Clinical and Experimental Medicine, University of Messina, AOU G. Martino PAD C, Via Consolare Valeria, 98100, Messina, Italy
| | - Michele Buemi
- Department of Clinical and Experimental Medicine, University of Messina, AOU G. Martino PAD C, Via Consolare Valeria, 98100, Messina, Italy
| | - Domenico Santoro
- Department of Clinical and Experimental Medicine, University of Messina, AOU G. Martino PAD C, Via Consolare Valeria, 98100, Messina, Italy.
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15
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Slot-Steenks MMB, Hamdy NAT, van de Sande MAJ, Vriens D, Cleven AHG, Appelman-Dijkstra NM. Identifying the culprit lesion in tumor induced hypophosphatemia, the solution of a clinical enigma. Endocrine 2016; 54:642-647. [PMID: 27709474 PMCID: PMC5107201 DOI: 10.1007/s12020-016-1092-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 08/13/2016] [Indexed: 01/26/2023]
Abstract
Tumor-induced osteomalacia is a rare acquired metabolic bone disorder characterized by isolated renal phosphate wasting due to abnormal tumor production of fibroblast growth factor 23. We report the case of a 59 year old woman referred to our department with a long history of progressive diffuse muscle weakness and pain, generalized bone pains and multiple insufficiency fractures of heels, ankles and hips due to a hypophosphatemic osteomalacia. A fibroblast growth factor 23-producing phosphaturic mesenchymal tumor localized in the left quadriceps femoris muscle was identified 7 years after onset of symptoms. Excision of the tumor resulted in normalization of serum phosphate and fibroblast growth factor 23 levels and in complete resolution of the clinical picture with disappearance of all musculoskeletal symptoms. This case illustrates the diagnostic difficulties in establishing a diagnosis tumor-induced osteomalacia and in identifying the responsible tumor. Our case underscores the clinical need to investigate all patients with persistent musculoskeletal symptoms for hypophosphatemia. A systematic approach is of pivotal importance because early recognition and treatment of the metabolic abnormality can prevent deleterious effects of osteomalacia on the skeleton.
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Affiliation(s)
- Mathilde M Bruins Slot-Steenks
- Center for Bone Quality and Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Albinusdreef 2, Leiden, 2333 ZA, The Netherlands.
| | - Neveen A T Hamdy
- Center for Bone Quality and Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Albinusdreef 2, Leiden, 2333 ZA, The Netherlands
| | - Michiel A J van de Sande
- Center for Bone Quality and Department of Orthopedic Surgery, Leiden University Medical Center, Albinusdreef 2, Leiden, 2333 ZA, The Netherlands
| | - Dennis Vriens
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, Leiden, 2333 ZA, The Netherlands
| | - Arjen H G Cleven
- Department of Pathology, Leiden University Medical Center, Albinusdreef 2, Leiden, 2333 ZA, The Netherlands
| | - Natasha M Appelman-Dijkstra
- Center for Bone Quality and Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Albinusdreef 2, Leiden, 2333 ZA, The Netherlands
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Ruppe MD, Zhang X, Imel EA, Weber TJ, Klausner MA, Ito T, Vergeire M, Humphrey JS, Glorieux FH, Portale AA, Insogna K, Peacock M, Carpenter TO. Effect of four monthly doses of a human monoclonal anti-FGF23 antibody (KRN23) on quality of life in X-linked hypophosphatemia. Bone Rep 2016; 5:158-162. [PMID: 28326356 PMCID: PMC4926842 DOI: 10.1016/j.bonr.2016.05.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 04/15/2016] [Accepted: 05/11/2016] [Indexed: 12/11/2022] Open
Abstract
X-linked hypophosphatemia (XLH) is characterized by lower extremity deformities that lead to bone and/or joint pain that result from decreased renal tubular reabsorption leading to hypophosphatemia caused by elevated levels of fibroblast growth factor 23 (FGF23). Objective Validate the use of SF-36v2 Health Survey (SF-36v2) and the Western Ontario and McMaster Osteoarthritis Index (WOMAC) to measure previously unstudied health-related quality of life (HRQoL) in XLH patients and determine the change in HRQoL before and after treatment with KRN23, a human monoclonal anti-FGF23 antibody. Methods Twenty-eight adult outpatients with XLH received up to four doses of KRN23 administered subcutaneously every 28 days. General HRQoL was measured with the SF-36v2 and condition-related HRQoL with the WOMAC at baseline and study endpoint as a secondary outcome of a Phase 1/2, open-label, multicenter, dose-escalation trial. Results Testing for scale discriminant validity and convergent-divergent validity supported the use of these scales in the assessment of HRQoL in XLH. Both instruments indicated impairment of physical function at baseline with all mean scores showing a trend to improved health at study endpoint compared to baseline. When corrected for multiple comparisons, the score for Role Limitations due to physical health on the SF-36v2 which measures the patient's perception of their own chronic functional impairments due to poor physical health remained significantly improved (P < 0.05), increasing to the mean score of US adults. For the WOMAC, Physical Functioning and Stiffness scores were significantly improved (P < 0.05). Conclusion KRN23 administration was associated with significantly improved patient perception of their Physical Functioning and Stiffness due to their disease. This study demonstrates that the SF-36v2 and WOMAC are valid tools for assessing HRQoL in XLH. Quality of life was assessed in 26 XLH patients before and after 4 months of treatment with KRN23. All mean scores showed a trend of improved health after 4 doses of KRN23 treatment. Role limitations due to physical health was significantly improved after multiplicity correction. Patient reported outcomes can provide valuable information in evaluating new treatments for XLH.
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Affiliation(s)
- Mary D Ruppe
- Department of Medicine, Houston Methodist Hospital, Houston, TX, USA
| | | | - Erik A Imel
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Thomas J Weber
- Duke Clinical Bone Laboratories, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Takahiro Ito
- Kyowa Hakko Kirin Pharma Inc., Princeton, NJ, USA
| | | | | | | | - Anthony A Portale
- Department of Pediatrics, University of California San Francisco, CA, USA
| | - Karl Insogna
- Yale Center for X-Linked Hypophosphatemia, Yale University School of Medicine, New Haven, CT, USA
| | - Munro Peacock
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Thomas O Carpenter
- Yale Center for X-Linked Hypophosphatemia, Yale University School of Medicine, New Haven, CT, USA
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17
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Yan L, Bowman MAH. Chronic sustained inflammation links to left ventricular hypertrophy and aortic valve sclerosis: a new link between S100/RAGE and FGF23. Inflamm Cell Signal 2014; 1. [PMID: 26082935 DOI: 10.14800/ics.279] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Cardiovascular disease including left ventricular hypertrophy, diastolic dysfunction and ectopic valvular calcification are common in patients with chronic kidney disease (CKD). Both S100A12 and fibroblast growth factor 23 (FGF23) have been identified as biomarkers of cardiovascular morbidity and mortality in patients with CKD. We tested the hypothesis that human S100/calgranulin would accelerate cardiovascular disease in mice subjected to CKD. METHODS This review paper focuses on S100 proteins and their receptor for advanced glycation end products (RAGE) and summarizes recent findings obtained in novel developed transgenic hBAC-S100 mice that express S100A12 and S100A8/9 proteins. A bacterial artificial chromosome of the human S100/calgranulin gene cluster containing the genes and regulatory elements for S100A8, S100A9 and S100A12 was expressed in C57BL/6J mice (hBAC-S100). CKD was induced by ureteral ligation, and hBAC-S100 mice and WT mice were studied after 10 weeks of chronic uremia. RESULTS hBAC-S100 mice with CKD showed increased FGF23 in the heart, left ventricular hypertrophy (LVH), diastolic dysfunction, focal cartilaginous metaplasia and calcification of the mitral and aortic valve annulus together with aortic valve sclerosis. This phenotype was not observed in WT mice with CKD or in hBAC-S100 mice lacking RAGE with CKD, suggesting that the inflammatory milieu mediated by S100/RAGE promotes pathological cardiac hypertrophy in CKD. In vitro, inflammatory stimuli including IL-6, TNFα, LPS, or serum from hBAC-S100 mice up regulated FGF23 mRNA and protein in primary murine neonatal and adult cardiac fibroblasts. CONCLUSIONS Taken together, our study shows that myeloid-derived human S100/calgranulin is associated with the development of cardiac hypertrophy and ectopic cardiac calcification in a RAGE dependent manner in a mouse model of CKD. We speculate that FGF23 produced by cardiac fibroblasts in response to cytokines may act in a paracrine manner to accelerate LVH and diastolic dysfunction in hBAC-S100 mice with CKD. We suggest that S100/RAGE-mediated chronic sustained systemic inflammation is linked to pathological cardiac remodeling via direct up regulation of FGF23 in cardiac fibroblasts, thereby providing a new mechanistic understanding for the common association between CKD, diabetes, metabolic syndrome, or hypertension with left ventricular hypertrophy with diastolic dysfunction.
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Affiliation(s)
- Ling Yan
- Department of Medicine, Section of Cardiology, The University of Chicago, Chicago, IL 60637 USA
| | - Marion A Hofmann Bowman
- Department of Medicine, Section of Cardiology, The University of Chicago, Chicago, IL 60637 USA
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Zou H, Zhao X, Sun N, Zhang S, Sato T, Yu H, Chen Q, Weber HP, Dard M, Yuan Q, Lanske B. Effect of chronic kidney disease on the healing of titanium implants. Bone 2013; 56:410-5. [PMID: 23876979 PMCID: PMC3812922 DOI: 10.1016/j.bone.2013.07.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Revised: 06/29/2013] [Accepted: 07/01/2013] [Indexed: 02/05/2023]
Abstract
Chronic kidney disease (CKD) has become a worldwide public health problem. However, its effect on osseointegration of dental implants is largely unknown. The aim of this study is to investigate whether CKD impairs the quality of the osseointegration of titanium implants. Uremia was induced by 5/6 nephrectomy in mice, and serum levels of BUN, FGF23, PTH and ALP were significantly increased. For in vitro tests, bone marrow mesenchymal stem cells (BMMSCs) were obtained and cultured on titanium discs. There was no significant difference in term of expression of osteogenic marker genes including Osx, Col-1, Ocn, and Opn, as quantified by qPCR. Moreover, Alizarin Red S staining showed comparable mineralized nodules formation. Histomorphometrical analysis of experimental implants inserted in the femurs of CKD mice revealed a trend of decreased BIC ratio at 2-week healing. The strength of bone-implant integration, as measured by a push-in method, was significantly lower for the CKD group at 2 weeks, although a comparable level was reached at 4 weeks. These results demonstrated that CKD only negatively affects the osseointegration of titanium implants at the early stage.
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Affiliation(s)
- Huawei Zou
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Xuefeng Zhao
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Ningyuan Sun
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Shiwen Zhang
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Tadatoshi Sato
- Department of Oral Medicine, Infection, and Immunity, Harvard School of Dental Medicine, Boston, MA, USA
| | - Haiyang Yu
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Qianming Chen
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Hans-Peter Weber
- Department of Prosthodontics and Operative Dentistry, Tufts University School of Dental Medicine, Boston, MA, USA
| | - Michel Dard
- New York University, College of Dentistry, Department of Periodontology and Implant Dentistry, NY, USA
| | - Quan Yuan
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- Department of Oral Medicine, Infection, and Immunity, Harvard School of Dental Medicine, Boston, MA, USA
- Corresponding author at: State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, 14 Third Section, Renmin Nan Road, Chengdu 610041, China. (Q. Yuan)
| | - Beate Lanske
- Department of Oral Medicine, Infection, and Immunity, Harvard School of Dental Medicine, Boston, MA, USA
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