Use of a Phosphorus Points Education Program to Maintain Normal Serum Phosphorus in Pediatric Chronic Kidney Disease: A Case Report.

A 14-year-old male, with chronic kidney disease stage 4 (glomerular filtration rate 20 mL/min/1.73 m2) secondary to reflux nephropathy required dietary modification with evidence of renal osteodystrophy, presented with elevated serum phosphorus and parathyroid hormone. He was educated using a novel phosphorus point system where 1 point is equivalent to ∼50 mg of phosphorus. Dietary counseling was provided by a pediatric renal dietitian on phosphorus content of foods the patient typically consumed and converted to point system for daily tracking. The family reported limiting daily phosphorus points to less than 20 points daily for 15 months. The family completed a 3-day food record and provided points assigned to each food item. A Spearman's correlation of 0.7 (P < .001) was found between the family's and the dietitian's assignment of phosphorus points. The patient's recorded phosphorus intake remained below 1000 mg each day and met estimated calorie and protein needs. The patient also continued with age-appropriate weight gain and linear growth. Laboratory values showed phosphorus and intact parathyroid hormone remained within desired range. A phosphorus point system tool can be used to maintain normal serum phosphorus levels and subsequently prevent secondary hyperparathyroidism in patients with pediatric chronic kidney disease.

Impact of Prophylaxis on Bone Mineral Metabolism in Children With Hemophilia.

In this study, we aimed to investigate changes in calcium (Ca) metabolism in hemophilia patients (PWH). We also aimed to investigate the importance of diagnosis and treatment of factors impairing calcium metabolism and the significance of early diagnosis and prophylaxis with respect to these subjects. For all patients, serum calcium, phosphorus, alkaline phosphatase, 25 hydroxy vitamin D (25-OHD), parathormone (PTH), and calcitonin levels were evaluated. Bone mineral density (BMD) was assessed by dual-energy x-ray absorptiometry. Low BMD scores and 25-OHD deficiency were observed in 29 (74.4%) and 34 (87.2%) patients, respectively. Prophylaxis of PWH did not differ significantly in terms of 25-OHD levels and BMD scores. Patients in the prophylaxis group had significantly higher PTH levels (P=0.042). A negative correlation was found between PTH measurements and Z-score (P=0.008). In summary, our findings, with a small number of PWH in our study group, suggest that biochemical markers of bone turnover may be used to detect bone loss. Follow-up through annual BMD measurements coupled with appropriate exercise programs could be recommended.

Pharmacodynamics of evocalcet for secondary hyperparathyroidism in Japanese hemodialysis patients.

BACKGROUND: This study investigated the pharmacokinetics, pharmacodynamics, and safety of multiple doses of evocalcet in Japanese secondary hyperparathyroidism (SHPT) patients receiving hemodialysis. METHODS: In this multicenter, open-label study, conducted between August 2013 and March 2014, 27 patients received multiple doses of 1 and 4 mg evocalcet for 14 days, followed by an extension period of multiple doses of 8 and 12 mg evocalcet for 7 days using an intra-patient dose escalation protocol. Pharmacodynamic parameters consisted of measurement of intact parathyroid hormone (PTH), serum-corrected calcium, serum phosphorus and intact fibroblast growth factor 23 concentrations. Safety was assessed by analysis of adverse events. RESULTS: Plasma evocalcet levels reached steady state 3 days after the first day of administration. Pharmacodynamic analyses showed that evocalcet effectively reduced intact PTH and serum-corrected calcium levels. Adverse events (AEs) occurred in 29.6 and 62.5% of patients receiving multiple doses of 1 or 4 mg, respectively. The AE 'blood calcium decreased' occurred in eight patients (33.0%) after multiple doses of 4 mg. All events were mild, except for one patient with a moderate AE (abnormal liver function) and one patient with a severe adverse drug reaction (blood calcium decreased). CONCLUSION: Multiple doses of evocalcet reduced intact PTH levels with a concomitant decrease in serum calcium levels. Evocalcet was well tolerated in SHPT patients receiving hemodialysis.

Efficacy and safety of sucroferric oxyhydroxide compared with sevelamer hydrochloride in Japanese haemodialysis patients with hyperphosphataemia: A randomized, open-label, multicentre, 12-week phase III study.

AIM: We aimed to investigate the non-inferiority of PA21 (sucroferric oxyhydroxide) to sevelamer hydrochloride (sevelamer) in terms of efficacy and safety in Japanese haemodialysis patients with hyperphosphataemia. METHODS: In this Phase III, open-label, multicentre study, 213 haemodialysis patients with hyperphosphataemia were randomized to PA21 or sevelamer treatment for 12 weeks. The primary outcome was adjusted serum phosphorus concentration at the end of treatment; the non-inferiority of PA21 was confirmed if the upper limit of the two-sided 95% confidence interval (CI) is ≤0.32 mmol/L. Secondary outcomes were corrected serum calcium and intact-parathyroid hormone concentrations. Adverse events (AEs) and adverse drug reactions (ADRs) were evaluated. RESULTS: The adjusted mean serum phosphorus concentration at the end of treatment confirmed the non-inferiority of PA21 for lowering serum phosphorus compared with sevelamer (1.62 vs 1.72 mmol/L; difference, -0.11 mmol/L; 95% CI, -0.20 to -0.02 mmol/L). The mean daily tablet intake was 5.6 ± 2.6 and 18.7 ± 7.1 tablets in the PA21 and sevelamer groups, respectively. The incidences of AEs and ADRs were not significantly different between the two groups. CONCLUSION: The non-inferiority of PA21 to sevelamer was confirmed for the treatment of Japanese haemodialysis patients with hyperphosphataemia. PA21 was effective, safe, and well tolerated, while having a considerably lower pill burden than sevelamer.

Long-Term Assessment of the Safety and Efficacy of PA21 (Sucroferric Oxyhydroxide) in Japanese Hemodialysis Patients With Hyperphosphatemia: An Open-Label, Multicenter, Phase III Study.

OBJECTIVE: The objective of this article was to assess the safety and efficacy of long-term administration of PA21. DESIGN AND METHODS: Phase III, open-label, long-term study in 15 sites in Japan. SUBJECTS: Japanese hemodialysis patients (N = 161) with hyperphosphatemia aged ≥20 years undergoing stable maintenance hemodialysis 3 times weekly, for ≥12 weeks. INTERVENTION: After a 2-week observation period with their previous hyperphosphatemia therapy, patients began the 52-week treatment with PA21, which was administered orally at an initial dose of 250 mg, 3 times daily, immediately before every meal (dosing range between 750 and 3,000 mg/day). MAIN OUTCOME MEASURE: Safety was evaluated based on the development of adverse events and adverse drug reactions (ADRs). Efficacy was evaluated according to serum phosphorus concentration, corrected serum calcium concentration, and serum intact-parathyroid hormone concentration. RESULTS: The mean serum phosphorus concentration decreased from 5.46 ± 1.06 mg/dL at baseline to 5.00 ± 1.17 mg/dL at end of treatment. The serum phosphorus concentration was maintained within the target range (3.5-6.0 mg/dL) throughout the 52 weeks of the study period with a mean of 3.3 tablets per day of PA21. Most ADRs were mild, transient, and developed early during treatment, and the incidence was not shown to increase with long-term treatment. The most frequently reported ADR was diarrhea (22.4%). CONCLUSION: Treatment with PA21 was effective in lowering and maintaining target serum phosphorus concentrations in Japanese hemodialysis patients with hyperphosphatemia over 52 weeks. PA21 was generally well tolerated in the long term.

Long-Term Therapy Outcomes When Treating Chronic Kidney Disease Patients with Paricalcitol in German and Austrian Clinical Practice (TOP Study).

Paricalcitol is approved for prevention and therapy of secondary hyperparathyroidism (sHPT) in patients with chronic kidney disease (CKD), with only short-term data in clinical routine settings. A 12-month observational study was conducted in Germany and Austria (90 centers, 761 patients) from 2008 to 2013. Laboratory values, demographical, and clinical data were documented in 629 dialysis patients and 119 predialysis patients. In predialysis patients, median intact parathormone (iPTH) was 180.0 pg/mL (n = 105) at the start of the study, 115.7 pg/mL (n = 105) at last documentation, and 151.8 pg/mL (n = 50) at month 12, with 32.4% of the last documented iPTH values in the KDOQI (Kidney Disease Outcomes Quality Initiative) target range. In dialysis patients, median iPTH was 425.5 pg/mL (n = 569) at study start, 262.3 pg/mL (n = 569) at last documentation, and 266.1 pg/mL (n = 318) at month 12, with 36.5% of dialysis patients in the KDOQI target range. Intravenous paricalcitol showed more homogenous iPTH control than oral treatment. Combined analysis of all dialysis patients indicated comparable and stable mean serum calcium and phosphate levels throughout the study. Clinical symptoms, such as itching, bone pain, and fatigue, were improved compared with study entry. The spectrum and frequency of adverse events mirrored the known pattern for patients on dialysis. Paricalcitol is efficacious and has a consistent safety profile in sHPT over 12 months.

[Effect of cinacalcet combined with low-dose calcitriol on clinical outcome and bone metabolism in patients with severe secondary hyperparathyroidism].

OBJECTIVE: To observe the clinical outcome and the effect of the combination of cinacalcet hydrochloride with low-dose calcitriol on bone metabolism in maintenance hemodialysis (MHD) patients with severe secondary hyperparathyroidism (SHPT).
 Methods: Thirty SHPT patients were enrolled to receive treatment of cinacalcet combined with low-dose calcitriol, with inclusion criteria as follows: maintenance on MHD>6 months; serum intact parathyroid hormone (iPTH)>600 pg/mL; parathyroid glands with more than 1 nodules by ultrasonography; traditional therapy with no effects. All patients were given cinacalcet 25-75 mg and 0.5 µg calcitriol daily. Serum Ca, P, iPTH, bone metabolic markers and bone density were measured before and after treatment. The clinical symptoms and their changes were recorded.
 Results: The baseline levels of iPTH, Ca and P were (1787.3±1 321.0) pg/mL, (2.54±0.19) mmol/L, and (2.06±0.15) mmol/L, respectively. After 2 weeks of treatment, serum phosphorus decreased by 20%; after 1 and 3 months of treatment, iPTH decreased by 35% and 70%. Ca and P fell to (2.39±0.17) and (1.56±0.50) mmol/L (P<0.05), respectively. The symptoms of the patients relieved. The above indicators remained stable after 12 months. Moreover, after 6 months of treatment, the alkaline phosphatase, osteocalcin and ß-cross levels were decreased by 50%, 37% and 49%, respectively. The decline in patients' bone density was inhibited. No severe adverse events were observed.
 Conclusion: Cinacalcet hydrochloride combined with low dose calcitriol can improve high calcium, high phosphorus and high iPTH in MHD patients with severe SHPT, relieve symptoms, and improve bone metabolism. It can be used as a favorable choice for the treatment of SHPT.

The challenge of controlling phosphorus in chronic kidney disease.

The pathogenesis and management of chronic kidney disease-mineral bone disorders (CKD-MBD) has experienced major changes, but the control of serum phosphorus at all stages of CKD still seems to be a key factor to improve clinical outcomes. High serum phosphorus is the most important uremia-related, non-traditional risk factor associated with vascular calcification in CKD patients and in the general population. Phosphorus may also be one of the key elements linking vascular calcification with low bone turnover. The main hormones and factors that contribute to the kidney regulation of phosphorus and calcium include parathyroid hormone, FGF-23, klotho and 1,25-dihydroxyvitamin D (1,25(OH)2D). Serum phosphorus did not start rising until CKD 3b in contrast with the earlier changes observed with fibroblast growth factor-23 (FGF-23), Klotho, calcitriol and parathyroid hormone (PTH). Despite FGF-23 and PTH having synergic effects regarding phosphorus removal, they have opposite effects on 1,25(OH)2D3. At the same stages of CKD in which phosphorus retention appears to occur, calcium retention also occurs. As phosphorus accumulation is associated with poor outcomes, an important question without a clear answer is at which level-range should serum phosphorus be maintained at different stages of CKD to improve clinical outcomes. There are four main strategies to manage phosphate homeostasis; phosphorus dietary intake, administration of phosphate binder agents, effective control of hyperparathyroidism and to ensure in the CKD 5D setting, an adequate scheme of dialysis. Despite all the available strategies, and the introduction of new phosphate binder agents in the market, controlling serum phosphorus remains challenging, and hyperphosphatemia continues to be extremely common in CKD 5 patients. Furthermore, despite phosphate binding agents having proved to be effective in reducing serum phosphorus, their ultimate effects on clinical outcomes remain controversial. Thus, we still need well-designed, large-scale, placebo-controlled studies to definitively prove that the reduction of serum phosphorus by phosphate binders improves clinical outcomes.

Efficacy and its predictor in microwave ablation for severe secondary hyperparathyroidism in patients undergoing haemodialysis.

BACKGROUND: Microwave ablation (MWA) can be used to treat severe secondary hyperparathyroidism; however, its efficacy and the predictor of its efficacy are unclear. In this retrospective study we determined the predictor of efficacy of MWA and compared the efficacy of MWA and parathyroidectomy. MATERIALS AND METHODS: Patients with severe secondary hyperparathyroidism who had received MWA or parathyroidectomy were enrolled in the study. Participants with MWA were divided into response and no response groups based on efficacy. Possible predictors were analysed using logistic regression to determine efficacy predictors. The participants were divided into MWA and parathyroidectomy groups, and the efficacy (including rates of achieving recommended goals for intact parathyroid hormone (iPTH), calcium, and phosphorus levels) were compared between the two groups. RESULTS: Thirty-one participants were enrolled for predictor analysis. Only baseline iPTH level predicted efficacy (OR 0.997, P = 0.018). The optimal threshold value of iPTH for predicting efficacy was 1493.5 pg/mL. To compare efficacy, 30 patients were enrolled in MWA (18/30) and parathyroidectomy (12/30) groups. The rates of achieving recommended goals for iPTH levels varied between 0 and 60%; a significant difference was found between the groups at 5 months (P = 0.01). However, in the parathyroidectomy group, the iPTH level and rate of iPTH <124 pg/mL (lower limit of target range) were significantly lower than in the MWA group after treatment (40-75% versus 0-16.7%). CONCLUSION: Baseline iPTH level is a good predictor of MWA efficacy for severe secondary hyperparathyroidism; parathyroidectomy is more effective for severe secondary hyperparathyroidism than MWA.

Biological Impact of Recent Guidelines on Parenteral Nutrition in Preterm Infants.

OBJECTIVES: Recent guidelines for preterm neonates recommend early initiation of parenteral nutrition (PN) with high protein and relatively high caloric intake. This review considers whether these changes could influence homeostasis in very preterm infants during the first few postnatal weeks. METHODS: This systematic review of relevant literature from searches of PubMed and recent guidelines was reviewed by investigators from several perinatal centers in France. RESULTS: New recommendations for PN could be associated with metabolic acidosis via the increase in the amino acid ion gap, hyperchloremic acidosis, and ammonia acidosis. The introduction of high-intake amino acids soon after birth could induce hypophosphatemia and hypercalcemia, simulating a "repeat feeding-like syndrome" and could be prevented by the early intake of phosphorus, especially in preterm infants born after fetal growth restriction. Early high-dose amino acid infusions are relatively well tolerated in the preterm infant with regard to renal function. Additional studies, however, are warranted to determine markers of protein intolerance and to specify the optimal composition and amount of amino acid solutions. CONCLUSIONS: Optimal PN following new guidelines in very preterm infants, despite their demonstrated benefits on growth, may induce adverse effects on ionic homeostasis. Clinicians should implement appropriate monitoring to prevent and/or correct them.

Balancing nutrition and serum phosphorus in maintenance dialysis.

Elevated serum phosphorus levels are common in patients with chronic kidney disease and are associated with heart and vascular disease, conditions that in turn are associated with increased mortality. Accurately managing phosphorus intake by restricting dietary protein alone can prove challenging because protein from different sources can contain varying amounts of available phosphorus. Additives used in processed foods frequently are high in inorganic phosphorus, which is readily absorbed, compounding this difficulty. Recent evidence suggests that dietary protein restriction in some cases may do more harm than good in some patients treated with maintenance hemodialysis because protein restriction can lead to protein-energy wasting, which is associated with increased mortality. Accordingly, phosphorus binders are important for managing hyperphosphatemia in dialysis patients. Managing hyperphosphatemia in patients with late-stage chronic kidney disease requires an individualized approach, involving a combination of adequate dietary advice, phosphate-binder use, and adjustments to dialysis prescription. We speculate that increased use of phosphate binders could allow patients to eat more protein-rich foods and that communicating this to patients might increase their perception of their need for phosphate binders, providing an incentive to improve adherence. The aim of this review is to discuss the challenges involved in maintaining adequate nutrition while controlling phosphorus levels in patients on maintenance hemodialysis therapy.

Effect of lanthanum carbonate versus calcium-based phosphate binders in dialysis patients: a meta-analysis.

BACKGROUND: The effects of lanthanum carbonate (LC) vs. calciumbased phosphate binders in dialysis patients have been a matter of debate. METHODS: We electronically searched PubMed, Embase, CENTRAL, and CBM for all randomized controlled trials comparing LC with calcium-based phosphate binders in adult dialysis patients. Quality assessment was performed using the Cochrane risk of bias tool. Metaanalysis was conducted by RevMan 5.2. RESULTS: Nine studies were eligible for our meta-analysis. There was no significant difference in all-cause mortality (RR 0.84, 95% CI 0.25 - 2.83) and cardiovascular events (RR 0.84, 95% CI 0.55 - 1.29) between LC and calcium-based phosphate binders. LC was associated with similar proportions of phosphate-controlled patients (RR 0.63, 95% CI 0.27 - 1.44) and lower incidence of hypercalcemia (RR 0.13, 95% CI 0.05 - 0.35) in comparison to calcium-based phosphate binders. Compared with calcium salts, LC was associated with significantly lower serum calcium, similar serum Ca x P product and higher serum iPTH. CONCLUSION: Despite the trends observed, we found no statistically significant differences in all-cause mortality and cardiovascular events between LC and calcium-based phosphate binders in dialysis patients. The conclusion was limited by lack of large sample and long-term trials. LC could reduce the incidence of hypercalcemia while comparable with calcium-based phosphate binders in reducing serum phosphorus level.

Dietary and pharmacological modification of fibroblast growth factor-23 in chronic kidney disease.

Increased levels of phosphorus and fibroblast growth factor-23 (FGF-23) are strong predictors of cardiovascular morbidity and mortality. From a physiological perspective and supported by some data, phosphorus is the main driver for FGF-23 secretion. Therefore, it is conceivable that interventions aiming at restriction of phosphorus uptake from the gastrointestinal tract may lower serum FGF-23 levels and improve cardiovascular risk and subsequently survival. It is not currently known to what extend phosphorus and FGF-23 are independent risk factors, and therefore both need to be targeted. However, their respective metabolisms are tightly connected. Control of phosphorus levels in chronic kidney disease (CKD) patients is attempted mainly by restriction of dietary intake and the use of phosphorus binders. In this review, it is outlined that not just the amount of dietary phosphorus intake is important but also its type (organic vs. inorganic), its source (animal vs. plant derived), and the protein-to-phosphorus ratio in the bioavailability of phosphorus from food. This qualitative aspect of diet is likely a neglected aspect of dietary counseling in CKD. However, in more advanced stages of CKD, dietary restriction of phosphorus alone is usually not sufficient to control hyperphosphatemia, and phosphorus binders are indicated. The inexpensive, calcium-containing dietary phosphorus binders are used commonly worldwide. However, they are not suitable for every patient because of the association with elevated serum calcium, increase in vascular and valvular calcification scores, and cardiovascular and all-cause mortality. The calcium content itself in these binders has recently been implicated to upregulate FGF-23. For that reason, the noncalcium, aluminum-free agents such as sevelamer and lanthanum are being advocated. However, these drugs do not have a clearly defined effect on circulating levels of FGF-23. Although it is conceivable that targeting FGF-23 may lead to improved clinical outcomes, this remains speculative. Therefore, more studies are needed to answer the question if this can be achieved with any of the phosphorus binders, or by another (additional) pharmacological intervention.

[Clinical efficacy instant goat milk in the complex therapy and prevention of osteoporosis in patients with rheumatoid arthritis].

Osteoporosis (OP) in rheumatoid arthritis (RA) refers to a secondary immune-mediated metabolic osteopathy characterized by periarticular and systemic decreased bone mass, impaired bone strength and increased risk of fractures. According to some studies, adding milk in the diet helps to increase bone mineral density and to reduce the risk of osteoporosis and maintain normal levels of vitamin D. To study the state of mineral and bone metabolism in RA patients zeith osteopenic syndrome and to evaluate the effectiveness of treatment and prevention of OP by adding dry goat milk "Amalteya" in the diet. The study included 42 patients with a documented diagnosis of RA (ACR, 1987) - 23 men (mean age 59 years) and 19 postmenopausal women (mean age 62 years) with the presence of osteoporosis and osteopenia according to the dual-energy X-ray absorptiometry. 21 (50%) RA patients (main group) received standard antiosteoporotichesky (alendronate 70 mg/week + calcium 1000 mg/day + Vitamin D3 800 IU/day) therapy and milk powder Amalteya® (400 ml/day). The control group (21 patients with RA) received only standard antiosteoporotic therapy. Follow-up lasted for 6 months. The concentration of total calcium in the blood of RA patients was on average 2.33 mmol/l, ionized Ca - 1,18 mmol/l and inorganic P - 1,09 mmol/l, which corresponds to normal values. Vitamin D deficiency was found in 17,5% of patients, and failure - in 32,5% of patients with RA. After 6 months of the treatment it was found that b-CrossLaps levels tend to be reducing in both of the groups and with reduction of bone formation marker osteocalcin in the group not receiving goat milk. Also, due to the background of ongoing combinative therapy it was clear that concentrations of 1,25(OH)2D and 25(OH)D in the blood serum are increasing (by 18,5-28,2% at the main group and by 8,0-17,9% at the control group), however, inter-group differences was below the level of the reliable importance. It was strongly marked in the group who received goat's milk "Amalteya®". Reduced levels of vitamin D in the blood is typical for 50% of RA patients with osteopenic syndrome with normal values of calcium-phosphorus metabolism. Combination therapy and prevention of osteoporosis in patients with RA with an additional inclusion in the diet of the daily administration of 400 ml of goat's milk Amalthea® has a positive impact on bone metabolism.

Evaluation of a Novel Enteral Phosphorus Therapy with Enteral Nutrition during a National Intravenous Sodium Phosphate Shortage.

The purpose of this study was to evaluate the efficacy and safety of intragastric administration of small volumes of sodium enema solution containing phosphorus as phosphorus replacement therapy in critically ill patients with traumatic injuries who required continuous enteral nutrition. Adult patients (>17 years of age) who had a serum phosphorus concentration <3 mg/dL (0.97 mmol/L) were evaluated. Patients with a serum creatinine concentration >1.4 mg/dL (124 µmol/L) were excluded. Patients were given 20 mL of saline enema solution intragastrically, containing 34 mmol of phosphorus and mixed in 240 mL water. A total of 55% and 73% of patients who received one (n = 22) or two doses (n = 11) had an improvement in the serum phosphorus concentration, respectively. The serum phosphorus concentration increased from 2.5 [2.1, 2.8] mg/dL (0.81 [0.69, 0.90] mmol/L) to 2.9 [2.2, 3.0] mg/dL (0.94 [0.71, 0.97 mmol/L) for those who received two doses (p = 0.222). Excluding two patients with a marked decline in serum phosphorus by 1.3 mg/dL (0.32 mmol/L) resulted in an increase in the serum phosphorus concentration from 2.3 [2.0, 2.8] mg/dL (0.74 [0.65, 0.90] mmol/L) to 2.9 [2.5, 3.2] mg/dL (0.94 [0.81, 1.03] mmol/L; n = 9; p = 0.012). No significant adverse effects were noted. Our data indicated that intragastric phosphate administration using a small volume of saline enema solution improved the serum phosphorus concentrations in most patients.

Efficacy and safety of burosumab compared with conventional therapy in patients with X-linked hypophosphatemia: A systematic review.

Burosumab, a monoclonal antibody directed against the fibroblast growth factor 23 (FGF23), has been approved for the treatment of X-linked hypophosphatemia (XLH). We conducted a systematic review to compare the efficacy and safety of burosumab versus conventional therapy (phosphorus and calcitriol) on XLH treatment. After a comprehensive literature search on MEDLINE/PubMed and Embase, we found nine studies for inclusion in the analysis. Risk of bias was assessed, and a random-effects model was used to determine the effect size. Clinical, biochemical, and radiological parameters of disease severity before and after treatment were analyzed and expressed in standardized mean difference (SMD). Burosumab resulted in normalization of phosphate homeostasis with an increase in renal tubular phosphate reabsorption and significant resolution of skeletal lesions (change in Thacher's total rickets severity score SMD: -1.46, 95% confidence interval [CI]: -1.76 to -1.17, p < 0.001, improvement in deformities, and decline in serum alkaline phosphatase levels [SMD: 130.68, 95% CI: 125.26-136.1, p < 0.001)]. Conventional therapy led to similar improvements in all these parameters but to a lower degree. In adults, burosumab normalized phosphorus levels (SMD: 1.23, 95% CI: 0.98-1.47, p < 0.001) with resultant clinical improvement. Burosumab treatment was well tolerated, with only mild treatment-related adverse effects. The present review indicates a potential role for burosumab in improving rickets, deformities, and growth in children with XLH. Given its superior efficacy and safety profile, burosumab could be an effective therapeutic option in children. We suggest further studies comparing burosumab versus conventional therapy in children and adults with XLH.

Changes in Nutritional Outcomes After Roux-en-Y Gastric Bypass: A Systematic Review and Meta-Analysis.

BACKGROUND: Bariatric surgery (BS) is the most effective treatment for severe obesity and it has beneficial effects on glycemic control and metabolism outcomes. However, the effects of BS on nutritional outcomes are controversial. Therefore, we aimed to evaluate the changes in several nutritional outcomes after Roux-en-Y gastric bypass (RYGB). METHODS: A comprehensive search was performed using the following databases: PubMed, Embase, Web of Science, Cochrane Library, WanFang and Chinese National Knowledge Infrastructure. The following outcomes were evaluated: vitamin A, 25-hydroxyvitamin D [25(OH)D], calcium, phosphorus, parathormone (PTH), iron, ferritin, vitamin B12, folate, and zinc. The pooled outcomes were expressed as standard mean difference (SMD) and 95% confidence interval (CI) using a random effects model. RESULTS: Fifty-six studies including 5645 individuals with obesity met the inclusion criteria. Serum 25(OH)D (SMD = 0.78, 95%CI 0.38 to 1.20, P < 0.001), phosphorus (SMD = 0.48, 95%CI 0.22 to 0.74, P < 0.001), PTH (SMD = 0.35, 95%CI 0.11 to 0.59, P = 0.005), vitamin B12 (SMD = 1.11, 95%CI 0.41 to 1.80, P = 0.002), and folate (SMD = 1.53, 95%CI 0.77 to 2.28, P < 0.001) significantly increased after RYGB compared with the baseline. Serum ferritin (SMD = - 1.67, 95%CI - 2.57 to - 0.77, P < 0.001), vitamin A (SMD = - 0.64, 95%CI - 0.99 to - 0.29, P < 0.001), and plasma zinc (SMD = - 0.58, 95%CI - 1.09 to - 0.06, P = 0.027) significantly decreased after RYGB. No significant changes in serum calcium (SMD = - 0.14, 95%CI - 0.40 to 0.11, P = 0.219) and iron (SMD = 0.26, 95%CI - 0.11 to 0.64, P = 0.165) were observed after RYGB. CONCLUSIONS: Despite the increased levels of 25(OH)D, phosphorus, vitamin B12 and folate, this meta-analysis revealed the unfavorable nutritional consequences after RYGB.

Serum phosphorus in people with chronic kidney disease: you are what you eat.

This issue of Kidney International includes two important articles about serum phosphorus and its treatment. The article by Cannata-Andía and colleagues describes a rigorous observational study of the association between serum phosphorus level, phosphate binder use, and clinical outcomes including all-cause and cardiovascular mortality. The article by Mehrotra and colleagues addresses the association between serum phosphorus, socioeconomic status, and mortality among participants in the US-based KEEP program.

The effect of 2 different single injections of high dose of vitamin D on improving the depression in depressed patients with vitamin D deficiency: a randomized clinical trial.

The correlation between vitamin D deficiency and depression has recently been put forward and resulted in controversial findings. The present study was conducted to find out the effect of 2 single injections of 150,000 and 300,000 IU of vitamin D on improving the depression in depressed patients with vitamin D deficiency.This clinical trial study was carried out during 2011-2012 in Yazd, Islamic Republic of Iran. A total of 120 patients who had a Beck Depression Inventory II score of 17+ and were affected with vitamin D deficiency were randomly assigned to 3 groups of 40. They included G300, G150, and NTG. G300 and G150 received an intramuscular single dose of 300,000 and 150,000 IU of vitamin D, respectively, and the NTG group received nothing. After 3 months of intervention, the depression state, serum vitamin D, calcium, phosphorus, and parathormone were measured.The median of serum vitamin D after intervention were 60.2, 54.6, and 28.2 nmol/L (P < 0.001) for the G300, G150, and NTG, respectively. Percentages of vitamin D deficiency after intervention were 18, 20, and 91.2 for the groups, respectively. The serum calcium mean showed a statistically significant increase in just the 2 test groups receiving vitamin D. There was only significant difference in mean of Beck Depression Inventory II test score between G300 and NTG (P = 0.003).The results of the study revealed that first, the correction of vitamin D deficiency improved the depression state, and second, a single injection dose of 300,000 IU of vitamin D was safe and more effective than a 150,000-IU dose.

[Diagnostics and treatment of primary and secondary hyperparathyroidism].

The experience of treatment of 41 patients (aged 32-67 years) was presented in the article. The duration of disease was 2-5 years. Primary hyperparathyroidism was diagnosed in 16 patients and secondary--in 25. Diagnostics of the disease included clinical methods of treatment; studying levels of general and ionized calcium, phosphorus, parathormone; an ultrasound of thyroid and parathyroid glands, the substratum scintigraphy. All patients were undergone the operation. Adenomas of parathyroid glands were removed in the case of primary hyperparathyroidism including mini-access. Hyperplastic parathyroid glands (31/2) were disposed in the case of secondary hyperparathyroidism. Good immediate and long-term results were obtained.