Secondary hyperparathyroidism (CKD-MBD) treatment and the risk of dementia.

BACKGROUND: Elevated parathyroid hormone (PTH) levels have been reported as a potential risk factor for cognitive impairment. Compared with the general population, older adults with end-stage renal disease (ESRD) who are frequently affected by secondary hyperparathyroidism (SHPT) are at increased risk of developing dementia. The main objective of our study was to evaluate if the risk of dementia in older (age ≥66 years) ESRD patients differed if they were treated for SHPT. METHODS: Using the United States Renal Data System and Medicare claims, we identified 189 433 older adults without a diagnosis of dementia, who initiated dialysis between 2006 and 2016. SHPT treatment was defined as the use of vitamin D analogs, phosphate binders, calcimimetics or parathyroidectomy. We quantified the association between treated SHPT and incident dementia during dialysis using a multivariable Cox proportional hazards model with inverse probability weighting, considering SHPT treatment as a time-varying exposure. RESULTS: Of 189 433 older ESRD adults, 92% had a claims diagnosis code of SHPT and 123 388 (65%) were treated for SHPT. The rate of incident dementia was 6 cases per 100 person-years among SHPT treated patients compared with 11 cases per 100 person-years among untreated patients. Compared with untreated SHPT patients, the risk of dementia was 42% lower [adjusted hazard ratio (aHR) = 0.58, 95% confidence interval (CI): 0.56-0.59] among SHPT treated patients. The magnitude of the beneficial effect of SHPT treatment differed by sex (Pinteraction = .02) and race (Pinteraction ≤ .01), with females (aHR = 0.56, 95% CI: 0.54-0.58) and those of Asian (aHR = 0.51, 95% CI: 0.46-0.57) or Black race (aHR = 0.51, 95% CI: 0.48-0.53) having a greatest reduction in dementia risk. CONCLUSION: Receiving treatment for SHPT was associated with a lower risk of incident dementia among older patients with ESRD. This work provides additional support for the treatment of SHPT in older ESRD patients.

Influência do metil-jasmonato na formação de compostos voláteis do aroma em Bananas (Musa acuminata cv. Nanicão) e Laranjas (Citrus sinensis cv. Pera) / Influence of methyljasmonate on the formation of aroma volatile compounds in Bananas (Musa acuminata cv. Nanicão) and Oranges (Citrus sinensis cv. Pera)

O principal hormônio associado aos processos do amadurecimento é o etileno, porém, na formação de compostos voláteis nos frutos, observa-se que as auxinas, o ácido abscísico e os jasmonatos também podem atuar como reguladores. Estudos indicam que em frutos climatéricos deve haver uma interação entre o metil jasmonato (MeJA) e o etileno na formação de compostos voláteis, mas em frutos não-climatéricos tal interação não é tão evidente. Há evidências de que o MeJA atue na regulação de algumas vias metabólicas relacionadas ao amadurecimento em frutos, sendo capaz de induzir aumento na produção de várias classes de compostos voláteis, através da expressão de genes que codificam as enzimas relacionadas às suas vias biossintéticas. Neste sentido, o objetivo deste projeto foi avaliar o efeito do metil jasmonato sobre o padrão de produção de compostos voláteis do aroma em frutos climatéricos e não-climatéricos. Precedentes do laboratório de Química, Bioq. e Biol. Molecular de Alimentos indicam que o MeJA apresentou padrões diferentes de comportamento em frutos climatéricos e não-climatéricos no que tange a formação do aroma. Assim, o presente projeto tem por hipótese a diferença de influência que o MeJA exerce sobre a produção de compostos voláteis em frutos climatéricos e não-climatéricos. Para testar esta hipótese foi avaliado o efeito do tratamento com MeJA na produção de compostos voláteis do aroma durante o amadurecimento de banana (Musa acuminata, cv. Nanicão), como exemplo de fruto climatérico e laranja (Citrus sinensis cv Pêra) para não-climatéricos. Os frutos foram divididos em grupo controle e tratado com MeJA (10 ppm/24h), armazenados em caixas plásticas tampadas e lacradas. Após tratamento foram submetidos a análises diárias da produção de etileno por cromatrogafia gasosa (CG), cor da casca e pesagem. Baseado em escalas de cor e a polpa foi congelada em N2 líq. e armazenada a -80°C para posterior análise dos compostos voláteis por cromatografia gasosa acoplada à espectrometria de massas (GC-MS). Ésteres, álcoois, cetonas e aldeídos foram compostos majoritariamente identificados na banana e terpenos, aldeídos, ésteres na laranja. As Bananas sofreram influência no perfil de acetato de isoamila, butonoato de butila, isobutirato de isoamila e isolvalerato de isoamila do começo ao fim do tratamento com MeJA, e as laranjas o tratamento influenciou os compostos Cis-muirola-3-5-diene, gamageraniol, alfa-copaeno, valenceno, alfa-pineno, carvone, geranial, entre outros terpenos, aldeídos como 3-hexanal e 2-hexenal (E) e ésteres como butirato de etila, nerol e tiglato de etilo. Os ésteres em frutos são produzidos por várias isoformas das álcool acil transferases (AATs). Estudos explicam que, ao menos 31 transcritos de AATs foram identificados em bananas, sendo 8 com altos níveis de expressão. Assim, é plausível supor que tal variedade de transcritos, e por conseguinte as AATs que codificam, sejam reguladas por múltiplos fatores, o que pode incluir o MeJa dentre outros sinais hormonais. Os terpenos são formados a partir de duas rotas, a do ácido mevalônico (MVA) e a rota do metileritritol fosfato (MEP). Compostos como, D-limoneno (51) e beta-selineno (62) tiveram níveis relativos maiores nos frutos do grupo controle, enquanto compostos terpênicos como geranial (59), valenceno (79) e o-cimeno (128), apresentaram maiores níveis nos frutos tratados com MeJa, no primeiro dia após o tratamento. Os resultados mostraram que o tratamento hormonal com MeJA causou mudanças do início ao fim do amadurecimento na composição do aroma de bananas (Musa acuminata cv Nanicão) e laranjas (Citrus sinensis cv Pera)

The main hormone associated with ripening processes is ethylene, but in the formation of volatile compounds in fruits, auxins, abscisic acid and jasmonates can also act as regulators. Studies indicate that in climacteric fruits there should be an interaction between methyl jasmonate (MeJA) and ethylene in the formation of volatile compounds, but in nonclimacteric fruits such interaction is not so evident. There is evidence that MeJA acts in the regulation of some metabolic pathways related to fruit ripening, being able to induce an increase in the production of several classes of volatile compounds, through the expression of genes that encode enzymes related to their biosynthetic pathways. In this sense, the objective of this project was to evaluate the effect of methyl jasmonate on the production pattern of aroma volatile compounds in climacteric and non-climacteric fruits. Precedents from the Laboratory of Food Chemistry, Bioq. and Molecular Biol. Molecular Chemistry, Bioq. and Molecular Biol. of Foods laboratory indicate that MeJA showed different behavior patterns in climacteric and non-climacteric fruits regarding aroma formation. Thus, the present project hypothesizes the different influence that MeJA has on the production of volatile compounds in climacteric and non-climacteric fruits. To test this hypothesis the effect of MeJA treatment on the production of volatile aroma compounds during ripening of banana (Musa acuminata, cv. Nanicão) as an example for climacteric fruit and orange (Citrus sinensis cv Pêra) for non-climacteric fruit was evaluated. Fruits were divided into control and MeJA treated group (10 ppm/24h), stored in capped and sealed plastic boxes. After treatment they were subjected to daily analysis of ethylene production by gas chromatography (GC), peel color and weighing. Based on color scales and the pulp was frozen in liquid N2 and stored at -80°C for subsequent analysis of volatile compounds by gas chromatography coupled to mass spectrometry (GC-MS). Esters, alcohols, ketones and aldehydes were compounds mostly identified in banana and terpenes, aldehydes, esters in orange. Bananas were influenced in the profile of isoamyl acetate, butyl butonoate, isoamyl isobutyrate and isoamyl isolvalerate from the beginning to the end of the MeJA treatment, and oranges the treatment influenced the compounds Cis-myrola-3-5-diene, gamma-geraniol, alpha-copaene, valencene, alpha-pinene, carvone, geranial, among other terpenes, aldehydes like 3-hexanal and 2-hexenal (E), and esters like ethyl butyrate, nerol, and ethyl tiglate. Esters in fruits are produced by various isoforms of the alcohol acyl transferases (AATs). Studies explain that at least 31 AAT transcripts have been identified in bananas, 8 of which have high expression levels. Thus, it is plausible to assume that such a variety of transcripts, and therefore the AATs they encode, are regulated by multiple factors, which may include MeJa among other hormonal signals. Terpenes are formed from two routes, the mevalonic acid (MVA) route and the methylerythritol phosphate (MEP) route. Compounds such as, D-limonene (51) and beta-selinene (62) had higher relative levels in the fruits of the control group, while terpenic compounds such as geranial (59), valencene (79) and o-cymene (128), showed higher levels in the MeJa treated fruits on the first day after treatment. The results showed that the hormonal treatment with MeJA caused changes from the beginning to the end of ripening in the aroma composition of bananas (Musa acuminata cv Nanicão) and oranges (Citrus sinensis cv Pera)

Policosanol attenuates Pi-induced calcification via AMPK-mediated INSIGs expression in rat VSMCs.

Policosanol is a hypocholesterolemic derived from sugar cane and corn that downregulates blood cholesterol levels. It can further lower blood pressure and reduce liver inflammation. Policosanol can also affect vascular calcification, however, its molecular mechanisms are not well understood. This study investigated the effect of policosanol on vascular calcification and its molecular mechanism. Policosanol decreased the expression of inorganic phosphate (Pi)-induced osteogenic genes such as distal-less homeobox 5 (Dlx5) and runt-related transcription factor 2 (Runx2). In addition, following policosanol treatment, adenosine monophosphate-activated protein kinase (AMPK) phosphorylation increased in a time-dependent manner. The constitutively active form of AMPK (CA-AMPK) dramatically suppressed Pi-induced Dlx5 and Runx2 protein levels. Inactivation of AMPK using compound C (Com. C; AMPK inhibitor) recovered policosanol-suppressed Alizarin Red S staining levels. Insulin-induced genes (INSIGs) were induced by CA-AMPK, their overexpression suppressed Pi-induced Dlx5 and Runx2 expression. Taken together, the results demonstrate that policosanol inhibits Pi-induced vascular calcification by regulating AMPK-induced INSIG expression in vascular smooth muscle cells.

Resveratrol is an inhibitor of sodium-dependent inorganic phosphate transport in triple-negative MDA-MB-231 breast cancer cells.

Metastasis is a major cause of death in patients with breast cancer. A growing body of evidence has demonstrated the antitumour effects of resveratrol, a non-flavonoid polyphenol. Resveratrol inhibits metastatic processes, such as the migration and invasion of cancer cells. In several cancer types, the importance of inorganic phosphate (Pi) for tumor progression has been demonstrated. The metastatic process in breast cancer is associated with Na+ -dependent Pi transporters. In this study, we demonstrate, for the first time, that resveratrol inhibits the Na+ -dependent Pi transporter. Results from kinetic analysis shows that resveratrol inhibits Na+ -dependent Pi transport non-competitively. Resveratrol also inhibits adhesion/migration in MDA-MB-231 cells, likely related to inhibition of the Na+ -dependent Pi transporter.

Dietary calcium intake does not meet the nutritional requirements of children with chronic kidney disease and on dialysis.

BACKGROUND: Adequate calcium (Ca) intake is required for bone mineralization in children. We assessed Ca intake from diet and medications in children with CKD stages 4-5 and on dialysis (CKD4-5D) and age-matched controls, comparing with the UK Reference Nutrient Intake (RNI) and international recommendations. METHODS: Three-day prospective diet diaries were recorded in 23 children with CKD4-5, 23 with CKD5D, and 27 controls. Doses of phosphate (P) binders and Ca supplements were recorded. RESULTS: Median dietary Ca intake in CKD4-5D was 480 (interquartile range (IQR) 300-621) vs 724 (IQR 575-852) mg/day in controls (p = 0.00002), providing 81% vs 108% RNI (p = 0.002). Seventy-six percent of patients received < 100% RNI. In CKD4-5D, 40% dietary Ca was provided from dairy foods vs 56% in controls. Eighty percent of CKD4-5D children were prescribed Ca-based P-binders, 15% Ca supplements, and 9% both medications, increasing median daily Ca intake to 1145 (IQR 665-1649) mg/day; 177% RNI. Considering the total daily Ca intake from diet and medications, 15% received < 100% RNI, 44% 100-200% RNI, and 41% > 200% RNI. Three children (6%) exceeded the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) upper limit of 2500 mg/day. None with a total Ca intake < RNI was hypocalcemic, and only one having > 2 × RNI was hypercalcemic. CONCLUSIONS: Seventy-six percent of children with CKD4-5D had a dietary Ca intake < 100% RNI. Restriction of dairy foods as part of a P-controlled diet limits Ca intake. Additional Ca from medications is required to meet the KDOQI guideline of 100-200% normal recommended Ca intake. Graphical abstract.

Calciphylaxis epidemiology, risk factors, treatment and survival among French chronic kidney disease patients: a case-control study.

BACKGROUND: Calcific Uremic Arteriolopathy (CUA) is a rare disease, causing painful skin ulcers in patients with end stage renal disease. Recommendations for CUA management and treatment are lacking. METHODS: We conducted a retrospective cohort study on CUA cases identified in western France, in order to describe its management and outcome in average clinical practices. Selection was based on the Hayashi diagnosis criteria (2013) extended to patients with eGFR < 30 mL/min/1.73m2. Dialyzed CUA cases were compared with 2 controls, matched for age, gender, region of treatment and time period. RESULTS: Eighty-nine CUA cases were identified between 2006 and 2016, including 19 non dialyzed and 70 dialyzed patients. Females with obesity (55.1%) were predominant. Bone mineral disease abnormalities, inflammation and malnutrition (weight loss, serum albumin decrease) preceded CUA onset for 6 months. The multimodal treatment strategy included wound care (98.9%), antibiotherapy (77.5%), discontinuation of Vitamin K antagonists (VKA) (70.8%) and intravenous sodium thiosulfate (65.2%). 40.4% of the patients died within the year after lesion onset, mainly under palliative care. Surgical debridement, distal CUA, localization to the lower limbs and non calcium-based phosphate binders were associated with better survival. Risks factors of developing CUA among dialysis patients were obesity, VKA, weight loss, serum albumin decrease or high serum phosphate in the 6 months before lesion onset. CONCLUSION: CUA involved mainly obese patients under VKA. Malnutrition and inflammation preceded the onset of skin lesions and could be warning signs among dialysis patients at risk. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02854046, registered August 3, 2016.

A Kinetic Process to Determine the Interaction Type Between Two Compounds, One of Which Is a Reaction Product, Using Alkaline Phosphatase Inhibition as a Case Study.

This study describes the development of a new methodology based on a new integrated equation which allows the determination of the kinetic parameters for two mutually non-exclusive inhibitors when one of which is produced during the time-course reaction. Alkaline phosphatase simultaneously inhibited by phosphate and urea is used to illustrate this methodology, including the evaluation of interaction effects between them. Data analyses were carried out using two integrated velocity equations: exclusive linear mixed inhibition (EMI) and non-exclusive linear mixed inhibition (NEMI). Kinetic parameters are estimated using non-linear regression and results show that (i) the interaction between enzyme and the inhibitors urea and phosphate exhibit a mutually non-exclusive behavior; (ii) more specifically, these inhibitors are non-exclusive only in free enzyme (E) species; (iii) the inhibitors also show an interaction with enzyme classified as facilitation; (iv) phosphate is a competitive inhibitor and urea a mixed inhibitor; (v) the inhibition constant for phosphate is much lower than that determined for urea. In addition, a functional Excel Spreadsheet which can be adapted to any kinetic study is also included as a supplement.

Gut microbiota; an overlooked effect of phosphate binders.

Hyperphosphatemia is a mineral bone-disease that increases cardiovascular complications and all-cause mortality in chronic kidney disease (CKD) patients. Oral phosphate binders absorb the dietary phosphate to prevent its high plasma levels. Moreover, they can adsorb some uremic toxins and decrease inflammation. A few recent studies highlight an ignored effect of phosphate binders on gut microbiota. Phosphorous is a major nutrient for survival and reproduction of bacteria and its intestinal concentration may impact the activity and composition of the gut microbiota. CKD is a state of an altered gut microbiome and bacterial-derived uremic toxins stimulate cardiovascular disease and systemic inflammation. The identification of the impact of phosphate binders on gut opens a new era in nephrology and fill the existing gap in interpretation of beneficial effects of phosphate binders. This review aims to highlight the impact of oral phosphate binders on the gut microbiome in CKD.

Real-world prescribing and switching patterns of non-calcium containing phosphate binders in dialysis patients in South Korea
.

OBJECTIVE: Non-calcium containing phosphate binders (non-CPBs) are useful for the treatment of hyperphosphatemia without a concern of hypercalcemia in patients undergoing dialysis. However, due to their relatively high cost, prescribing non-CPBs is restricted in South Korea. This study was conducted to investigate prescribing patterns, especially switching between CPBs and non-CPBs, in dialysis patients in a real-world setting. MATERIALS AND METHODS: This is an observational study using the National Health Insurance Service claim data. The study population included patients who initiated dialysis between July 2012 and June 2013 and were prescribed phosphate binders at least once during the observation period (2012 - 2016) (n = 10,073). Medication costs and prescribing patterns including switching of phosphate binders were investigated. RESULTS: Compared with the first year of dialysis, the costs of phosphate binders more than doubled during the 4th year of dialysis (from US$ 28.4 to US$ 60.1), largely due to an increase in the cost of non-CPBs (from US$ 117.5 to US$ 237.8). Many patients continued to change drugs between CPBs and non-CPBs. The continuous prescription period of CPBs was shortened each time a drug was changed. A total of 551 patients (13.4%) changed their medication three times between CPBs and non-CPBs. CONCLUSION: Over time on dialysis, use of non-CPB increased and medication costs increased accordingly. Many patients continued to change drugs between CPBs and non-CPBs due to the restricted criteria of the health insurance. Further outcome research is necessary to evaluate the appropriateness of the clinical practice in which CPBs and non-CPBs are alternately used.

Regional prescription surveillance of phosphate binders in the western Saitama area: the substantial role of ferric citrate hydrate in improving serum phosphorus levels and erythropoiesis.

BACKGROUND: In April 2015, five types of phosphate binders (PBs) were available by prescription in Japan, namely calcium carbonate, sevelamer hydrochloride, lanthanum carbonate, bixalomer, and ferric citrate hydrate (FeC). FeC reduces serum phosphorus levels and increases the body's iron stores. However, it is unclear whether FeC lowers serum phosphorus relative to other agents in a regional practical setting. METHODS: We performed a retrospective observational cohort study of regional hemodialysis surveillance in the western Saitama area of Japan, which included 1374 hemodialysis patients enrolled from 32 satellite dialysis units. The clinical data and prescribing information were retrospectively collected and analyzed. The difference in serum phosphorus among the groups administered five types of PBs (new or additional) from April to September 2015 was the primary outcome. RESULTS: As of April 2015, the median values of serum phosphorus, corrected calcium, and intact parathyroid hormone were 5.4 mg/dL, 9.1 mg/dL, and 147 pg/dL, respectively (N = 1374). Unexpectedly, with an increase in the number of PBs administered, serum phosphorous levels increased (p < 0.001). The significant changes in the serum phosphorus and hemoglobin levels were associated with the prescription of FeC but not with that of the other PBs. CONCLUSIONS: This regional survey suggests that serum phosphorus is well managed and that FeC has the potential to reduce the serum phosphorus level relative to other PBs and to ameliorates anemia.

In-vitro Equilibrium Phosphate Binding Study of Sevelamer Carbonate by UV-Vis Spectrophotometry.

Sevelamer carbonate is a cross-linked polymeric amine; it is the active ingredient in Renvela® tablets. US FDA provides recommendation for demonstrating bioequivalence for the development of a generic product of sevelamer carbonte using in-vitro equilibrium binding study. A simple UV-vis spectrophotometry method was developed and validated for quantification of free phosphate to determine the binding parameter constant of sevelamer. The method validation demonstrated the specificity, limit of quantification, accuracy and precision of measurements. The validated method has been successfully used to analyze samples in in-vitro equilibrium binding study for demonstrating bioequivalence.

Dipeptidyl peptidase-4 inhibitor gemigliptin protects against vascular calcification in an experimental chronic kidney disease and vascular smooth muscle cells.

Although dipeptidyl peptidase-4 inhibitors, a class of antidiabetic drugs, have various pleiotropic effects, it remains undetermined whether gemigliptin has a beneficial effect on vascular calcification. Therefore, this study was performed to evaluate the effect of gemigliptin on vascular calcification in a rat model of adenine-induced chronic kidney disease and in cultured vascular smooth muscle cells. Gemigliptin attenuated calcification of abdominal aorta and expression of RUNX2 in adenine-induced chronic kidney disease rats. In cultured vascular smooth muscle cells, phosphate-induced increase in calcium content was reduced by gemigliptin. Gemigliptin reduced phosphate-induced PiT-1 mRNA expression, reactive oxygen species generation, and NADPH oxidase mRNA expression (p22phox and NOX4). The reduction of oxidative stress by gemigliptin was associated with the downregulation of phospho-PI3K/AKT expression. High phosphate increased the expression of frizzled-3 (FDZ3) and decreased the expression of dickkopf-related protein-1 (DKK-1) in the Wnt pathway. These changes were attenuated by gemigliptin treatment. Gemigliptin restored the decreased expression of vascular smooth muscle cells markers (α-SMA and SM22α) and increased expression of osteogenic makers (CBFA1, OSX, E11, and SOST) induced by phosphate. In conclusion, gemigliptin attenuated vascular calcification and osteogenic trans-differentiation in vascular smooth muscle cells via multiple steps including downregulation of PiT-1 expression and suppression of reactive oxygen species generation, phospho-PI3K/AKT, and the Wnt signaling pathway.

Isolation and identification of a novel bacterium, Lactobacillus sakei subsp. dgh strain 5, and optimization of growth condition for highest antagonistic activity.

In the present study, we isolated Lactobacillus sakei strain DGH5 from raw beef meat. This bacterium plays an inhibitory effect against food-spoiling bacteria and food-borne pathogens, including Listeria monocytogenes, a gram-positive and pathogenic bacterium. Lactobacillus sakei strain DGH5 was identified through both phenotypical and biochemical tests accompanied with 16S rRNA sequence analysis. Among all the sources of carbon, nitrogen and phosphorous forms, we selected the most potent compounds to optimize the condition for the highest antagonistic activity. Among the sugars, polygalacturonic acid demonstrated to improve the antagonistic activity. Ammonium nitrate demonstrated to be suitable nitrogen sources. Amongst phosphorous sources, disodium hydrogen phosphate had the greatest antagonistic effect. According to Taguchi's orthogonal array, temperature, disodium hydrogen phosphate and soy Peptone had significant effect on antagonistic activity. Furthermore, mean comparisons showed that the optimum conditions achieved at pH 6.0, 25 °C temperature, 1.5% (w/v) Na2HPO4 and 0.5% (w/v) peptone.

The role of phosphate in kidney disease.

The importance of phosphate homeostasis in chronic kidney disease (CKD) has been recognized for decades, but novel insights - which are frequently relevant to everyday clinical practice - continue to emerge. Epidemiological data consistently indicate an association between hyperphosphataemia and poor clinical outcomes. Moreover, compelling evidence suggests direct toxicity of increased phosphate concentrations. Importantly, serum phosphate concentration has a circadian rhythm that must be considered when interpreting patient phosphate levels. Detailed understanding of dietary sources of phosphate, including food additives, can enable phosphate restriction without risking protein malnutrition. Dietary counselling provides an often underestimated opportunity to target the increasing exposure to dietary phosphate of both the general population and patients with CKD. In patients with secondary hyperparathyroidism, bone can be an important source of serum phosphate, and adequate appreciation of this fact should impact treatment. Dietary and pharmotherapeutic interventions are efficacious strategies to lower phosphate intake and serum concentration. However, strong evidence that targeting serum phosphate improves patient outcomes is currently lacking. Future studies are, therefore, required to investigate the effects of modern dietary and pharmacological interventions on clinically meaningful end points.

Inhibition of Phosphate-Induced Vascular Smooth Muscle Cell Osteo-/Chondrogenic Signaling and Calcification by Bafilomycin A1 and Methylamine.

BACKGROUND/AIMS: Excessive phosphate concentrations trigger vascular calcification, an active process promoted by osteoinduction of vascular smooth muscle cells (VSMCs) with increased expression and activity of transcription factor RUNX2 (Core-binding factor α1, CBFA1), alkaline phosphatase (ALPL), TGFß1, transcription factor NFAT5, and NFAT5-sensitive transcription factor SOX9. The osteoinductive signaling and vascular calcification of hyperphosphatemic klotho-hypomorphic mice could be reversed by treatment with NH4Cl, effects involving decrease of TGFß1 and inhibition of NFAT5-dependent osteoinductive signaling. Known effects of NH4Cl include alkalinization of acidic cellular compartments. The present study explored whether osteo-/chondrogenic signaling could be influenced by alkalinization of acidic cellular compartments following inhibition of the vacuolar H+ ATPase with bafilomycin A1 or following dissipation of the pH gradient across the membranes of acidic cellular compartments with methylamine. METHODS: Primary human aortic smooth muscle cells (HAoSMCs) were treated with high phosphate to trigger osteo-/chondrogenic signaling and calcification in the absence or presence of bafilomycin A1 or methylamine. Calcium content was determined using a QuantiChrom Calcium assay, ALP activity by a colorimetric assay and transcript levels by quantitative RT-PCR. RESULTS: High phosphate increased significantly the calcium deposition, CBFA1 and ALPL mRNA expression as well as alkaline phosphatase activity in HAoSMCs, all effects ameliorated by both, bafilomycin A1 and methylamine. High phosphate further significantly up-regulated the mRNA levels of TGFB1, NFAT5 and SOX9, effects significantly blunted by additional treatment with bafilomycin A1 or methylamine. Treatment of HAoSMCs with human TGFß1 protein or high phosphate up-regulated NFAT5, SOX9, CBFA1 and ALPL mRNA expression to similarly high levels which could not be further increased by combined treatment with high phosphate and TGFß1. Bafilomycin A1 failed to reverse the osteo-/chondrogenic signaling triggered by high phosphate together with TGFß1. CONCLUSIONS: Inhibition of the vacuolar H+ ATPase or dissipation of the pH gradient across the membranes of acidic cellular compartments both disrupt osteo-/chondrogenic signaling and calcium deposition in VSMCs, observations supporting the hypothesis that vascular calcification requires acidic cellular compartments.

Rationale and Approaches to Phosphate and Fibroblast Growth Factor 23 Reduction in CKD.

Patients with CKD often progress to ESRD and develop cardiovascular disease (CVD), yet available therapies only modestly improve clinical outcomes. Observational studies report independent associations between elevated serum phosphate and fibroblast growth factor 23 (FGF23) levels and risks of ESRD, CVD, and death. Phosphate excess induces arterial calcification, and although elevated FGF23 helps maintain serum phosphate levels in the normal range in CKD, it may contribute mechanistically to left ventricular hypertrophy (LVH). Consistent epidemiologic and experimental findings suggest the need to test therapeutic approaches that lower phosphate and FGF23 in CKD. Dietary phosphate absorption is one modifiable determinant of serum phosphate and FGF23 levels. Limited data from pilot studies in patients with CKD stages 3-4 suggest that phosphate binders, low phosphate diets, or vitamin B3 derivatives, such as niacin or nicotinamide, may reduce dietary phosphate absorption and serum phosphate and FGF23 levels. This review summarizes current knowledge regarding the deleterious systemic effects of phosphate and FGF23 excess, identifies questions that must be addressed before advancing to a full-scale clinical outcomes trial, and presents a novel therapeutic approach to lower serum phosphate and FGF23 levels that will be tested in the COMBINE Study: The CKD Optimal Management With BInders and NicotinamidE study.

Sucroferric oxyhydroxide: a review in hyperphosphataemia in chronic kidney disease patients undergoing dialysis.

Sucroferric oxyhydroxide (Velphoro®), an iron-based oral phosphate binder, is available for the control of serum phosphorus levels in patients with chronic kidney disease (CKD) on dialysis. In a pivotal phase III trial, sucroferric oxyhydroxide 1000-3000 mg/day for 24 weeks was noninferior to sevelamer carbonate 4800-14,400 mg/day with regard to lowering serum phosphorus levels. Additionally, sucroferric oxyhydroxide at maintenance dosages was significantly more effective than low dosage sucroferric oxyhydroxide (250 mg/day) with regard to maintaining controlled serum phosphorus levels during weeks 24-27 of treatment. Sucroferric oxyhydroxide had a numerically lower mean daily pill burden and better treatment adherence than sevelamer carbonate. Treatment with sucroferric oxyhydroxide was generally well tolerated over 24 weeks' treatment, with the most frequently reported treatment-emergent adverse events being mild, transient diarrhoea and discoloured faeces. In a 28-week extension study, the efficacy and tolerability profile of sucroferric oxyhydroxide remained similar to sevelamer carbonate for up to 52 weeks. In conclusion, sucroferric oxyhydroxide is a valuable treatment option for hyperphosphataemia in CKD patients on dialysis, providing an effective and generally well tolerated noncalcium-based phosphate binder therapy with a lower pill burden than sevelamer carbonate and the potential for improved treatment adherence.

Efficacy and acceptability of the new oral phosphate binder Lenziaren(®) in healthy cats fed a renal diet.

The efficacy and acceptability of the new oral phosphate binder Lenziaren(®) (SBR759) were evaluated in healthy cats fed with a commercial diet containing low amounts of phosphate ('renal diet'). Lenziaren(®) at 0.125, 0.25, 0.5 and 1 g/day was compared to a reference product Lantharenol(®) (3.0 g/day) and a placebo in a masked, randomized, parallel-group design study in 36 cats (n = 6 per group). All products were mixed with the ration which was fed once daily for 28 days. Lenziaren(®) produced significant dose-related reductions in serum and urine phosphate concentrations, faecal apparent phosphorus digestibility and fractional urinary phosphate excretion. Cats administered Lenziaren(®) consumed significantly less food than the placebo group, but this had no negative impact on body weight or acceptability assessments. When compared to the positive control, Lantharenol(®) , Lenziaren(®) was significantly more acceptable (0.125, 0.5 and 1.0 g/day doses), was associated with higher food consumption (0.125, 0.5 and 1.0 g/day doses) and had greater efficacy in reducing serum phosphate (0.5 and 1.0 g/day) and urine phosphate concentrations (1.0 g/day). In conclusion, Lenziaren(®) was an effective oral phosphate binder in healthy cats fed with a renal diet. Lenziaren(®) was well accepted and tolerated. Dosages of 0.25-1.0 g/cat per day are recommended for clinical testing.

Profiling patient attitudes to phosphate binding medication: a route to personalising treatment and adherence support.

OBJECTIVE: Nonadherence to phosphate binding medication (PBM) compromises the efficacy of treatment for chronic kidney disease, but its causes are poorly understood. This study sought to explore patient attitudes towards PBM and to evaluate the utility of the necessity-concerns framework for understanding adherence to PBM. DESIGN: A sample of 221 dialysis patients currently prescribed PBM were surveyed from eight UK renal units. MAIN OUTCOME MEASURES: Demographic data and clinical information, alongside the Beliefs about Medicines Questionnaire and the medication adherence report scale were reported. RESULTS: Low adherence to PBM was predicted by reduced beliefs in personal need for PBM (OR = .34; 95% CI: .14-.83; p < .05), and increased concerns about PBM (OR = 3.17; 95% CI: 1.87-5.37; p < .001). Patients were categorised into attitudinal groups based on their beliefs about PBM and being 'skeptical' of PBM (low necessity beliefs and high concerns) was most associated with low adherence. CONCLUSION: Strategies to improve adherence to PBM should aim to elicit and address patients' beliefs about their personal need for PBM and their concerns about this medication.

Differential effects of indoxyl sulfate and inorganic phosphate in a murine cerebral endothelial cell line (bEnd.3).

Endothelial dysfunction plays a key role in stroke in chronic kidney disease patients. To explore the underlying mechanisms, we evaluated the effects of two uremic toxins on cerebral endothelium function. bEnd.3 cells were exposed to indoxyl sulfate (IS) and inorganic phosphate (Pi). Nitric oxide (NO), reactive oxygen species (ROS) and O2•⁻ were measured using specific fluorophores. Peroxynitrite and eNOS uncoupling were evaluated using ebselen, a peroxide scavenger, and tetrahydrobiopterin (BH4), respectively. Cell viability decreased after IS or Pi treatment (p < 0.01). Both toxins reduced NO production (IS, p < 0.05; Pi, p < 0.001) and induced ROS production (p < 0.001). IS and 2 mM Pi reduced O2•⁻ production (p < 0.001). Antioxidant pretreatment reduced ROS levels in both IS- and Pi-treated cells, but a more marked reduction of O2•⁻ production was observed in Pi-treated cells (p < 0.001). Ebselen reduced the ROS production induced by the two toxins (p < 0.001); suggesting a role of peroxynitrite in this process. BH4 addition significantly reduced O2•⁻ and increased NO production in Pi-treated cells (p < 0.001), suggesting eNOS uncoupling, but had no effect in IS-treated cells. This study shows, for the first time, that IS and Pi induce cerebral endothelial dysfunction by decreasing NO levels due to enhanced oxidative stress. However, Pi appears to be more deleterious, as it also induces eNOS uncoupling.