Educación alimentaria en pacientes en dialisis / Nutritional education in dialysis patients

La enfermedad renal crónica terminal aumenta el riesgo cardiovascular y puede ocasionar defectos en la mineralización ósea. Para prevenir esto, se debe mantener el fósforo plasmático normal, que depende de la diálisis, los quelantes y la ingesta de fósforo, principalmente de origen inorgánico, incorporado mediante aditivos alimentarios. Las intervenciones nutricionales son pilares en el tratamiento de estos pacientes. El objetivo es facilitar estrategias alimentarias a un grupo de pacientes pediátricos en diálisis, mediante educación alimentaria nutricional, para aumentar el consumo de alimentos naturales, disminuyendo la ingesta de fósforo inorgánico especialmente de los productos cárnicos procesados. Materiales y métodos: se estudió una población pediátrica en diálisis. Se preparó un programa educativo con atención personalizada, instrucción alimentaria y seguimiento mensual, seguido de un taller. Resultados: n: 17 pacientes, edad decimal media de 12,3, 53% sexo masculino, 88% en hemodiálisis. Previo a la intervención el 64,7% consumía productos cárnicos procesados. Luego del taller el 58,8% disminuyó su consumo, el 41,2% aumentó la ingesta de preparaciones caseras, el 53% incorporó nuevos condimentos, de los cuales el 89% presentó al incorporarlos, mejor aceptación a las preparaciones. Conclusiones: la hiperfosfatemia está presente en alrededor del 50% de los pacientes en diálisis asociándose a un incremento entre 20% al 40% del riesgo de mortalidad. La presencia de fósforo oculto en los alimentos y la falta de adherencia hacen prioritario trabajar en programas educativos que favorezcan el aprendizaje colaborativo, centralizados en prácticas culinarias, para brindar herramientas que faciliten una alimentación natural, disminuyendo el consumo de ultraprocesados (AU)

Chronic end-stage renal disease increases the risk of cardiovascular disease and may lead to defects in bone mineralization. In order to prevent these risks, normal plasma phosphorus levels should be maintained. Achieving this goal depends on dialysis, chelators, and phosphorus intake, mainly of inorganic origin, incorporated through food supplements. Nutritional interventions are crucial in the treatment of these patients. The objective is to facilitate nutritional strategies to a group of pediatric dialysis patients, through food education, to increase the consumption of natural foods, decreasing the intake of inorganic phosphorus, especially from processed meat products. Materials and methods: a pediatric population undergoing dialysis was studied. An educational program was prepared with personalized care, nutritional instruction, and monthly follow-up visits, followed by a workshop. Results: n: 17 patients, mean age 12.3 years, 53% male, 88% on hemodialysis. Prior to the intervention, 64.7% consumed processed meat products. After the workshop, 58.8% decreased their consumption, 41.2% increased the intake of homemade food, 53% incorporated new seasonings, of whom 89% reported better acceptance of the preparations when they were incorporated. Conclusions: hyperphosphatemia is observed in around 50% of patients undergoing dialysis and is associated with a 20% to 40% increased risk of mortality. The presence of hidden phosphorus in food and the lack of adherence point to the need for the development of educational programs that promote collaborative learning, focusing on food-preparation practices. These programs should provide tools that facilitate a natural diet, reducing the consumption of ultra-processed food (AU)

Involvement of estrogen in phosphorus-induced nephrocalcinosis through fibroblast growth factor 23.

Excessive phosphorus intake adversely affects bone and mineral metabolism. Estrogen is one of the factors affecting fibroblast growth factor 23 (FGF23), a phosphorus-regulating hormone. However, the interaction between excess phosphorus and estrogen status has not been fully elucidated. This study investigated the involvement of estrogen in the effects of high phosphorus intake on bone metabolism and ectopic calcification in ovariectomized (OVX) rats. The interaction between high phosphorus diet and OVX was not observed in bone mineral density and aortic calcium. In contrast, high phosphorus intake markedly increased renal calcium concentration in sham rats, whereas the effect was attenuated in OVX rats, which was reversed by a selective estrogen-receptor modulator treatment. A strong positive correlation between renal calcium and serum FGF23 was observed. In addition, fibroblast growth factor receptor 1 (FGFR1: a predominant receptor of FGF23) inhibitor treatment partially decreased renal calcium concentrations in rats with high phosphorus intake. In conclusion, the effect of high phosphorus intake on bone metabolism and aortic calcification did not depend on the estrogen status; in contrast, high phosphorus intake synergistically induced nephrocalcinosis in the presence of estrogenic action on the bone. Furthermore, FGF23 was involved in the nephrocalcinosis induced by high phosphorus intake partially through FGFR1 signaling.

Yellow phosphorus-induced Brugada phenocopy.

BACKGROUND: Metallic phosphides (of aluminum and phosphide) and yellow phosphorus are commonly used rodenticide compounds in developing countries. Toxicity of yellow phosphorus mostly pertains to the liver, kidney, heart, pancreas and the brain. Cardiotoxicity with associated Brugada ECG pattern has been reported only in poisoning with metallic phosphides. METHODS AND RESULTS: Brugada phenocopy and hepatic dysfunction were observed in a 29-year-old male following yellow phosphorus consumption. He had both type 1 (day1) and type 2 (day2) Brugada patterns in the electrocardiogram, which resolved spontaneously by the third day without hemodynamic compromise. CONCLUSION: Toxins such as aluminum and zinc phosphide have been reported to induce Brugada ECG patterns due to the generation of phosphine. We report the first case of yellow phosphorus-related Brugada phenocopy, without hemodynamic compromise or malignant arrhythmia.

Phosphorus dendrimers for nanomedicine.

From biomaterials to imaging, and from drug delivery to drugs by themselves, phosphorus-containing dendrimers offer a large palette of biological properties, depending essentially on their types of terminal functions. The most salient examples of phosphorus dendrimers used for the elaboration of bio-chips and of supports for cell cultures, for imaging biological events, and for carrying and delivering drugs or biomacromolecules are presented in this feature article. Several phosphorus dendrimers can be considered also as drugs per se (by themselves) in particular to fight against cancers, neurodegenerative diseases, and inflammation, both in vitro and in vivo. Toxicity assays are also reported.

Cyanobacterial Toxins of the Laurentian Great Lakes, Their Toxicological Effects, and Numerical Limits in Drinking Water.

Cyanobacteria are ubiquitous phototrophic bacteria that inhabit diverse environments across the planet. Seasonally, they dominate many eutrophic lakes impacted by excess nitrogen (N) and phosphorus (P) forming dense accumulations of biomass known as cyanobacterial harmful algal blooms or cyanoHABs. Their dominance in eutrophic lakes is attributed to a variety of unique adaptations including N and P concentrating mechanisms, N2 fixation, colony formation that inhibits predation, vertical movement via gas vesicles, and the production of toxic or otherwise bioactive molecules. While some of these molecules have been explored for their medicinal benefits, others are potent toxins harmful to humans, animals, and other wildlife known as cyanotoxins. In humans these cyanotoxins affect various tissues, including the liver, central and peripheral nervous system, kidneys, and reproductive organs among others. They induce acute effects at low doses in the parts-per-billion range and some are tumor promoters linked to chronic diseases such as liver and colorectal cancer. The occurrence of cyanoHABs and cyanotoxins in lakes presents challenges for maintaining safe recreational aquatic environments and the production of potable drinking water. CyanoHABs are a growing problem in the North American (Laurentian) Great Lakes basin. This review summarizes information on the occurrence of cyanoHABs in the Great Lakes, toxicological effects of cyanotoxins, and appropriate numerical limits on cyanotoxins in finished drinking water.

Salivary calcium and phosphate stability in different time and temperature storage

ABSTRACT The non-invasive collection and inexpensive nature of saliva has made it an attractive sample for use for diagnosis and research on several diseases. Storage circumstances may affect salivary component concentrations. The objective was to analyze calcium and phosphate stability in saliva samples stored at different conditions. Saliva of healthy people was stored and analyzed by spectrophotometry under different time and temperature conditions in order to evaluate calcium and phosphate stability. Calcium concentration was measured by Arsenazo III reaction at 600nm and phosphate by an acid-molybdate method at 650nm. Using Lin's concordance correlation coefficient (k), we observed very good agreement (k>0.8) for all samples frozen at -20 oC up to 50 days. Thaw/refreezing cycles can compromise phosphate stability even though there is good agreement (0.61<k<0.8). Because of higher variability for refrigerated samples, they are not the best storage method, although calcium and phosphate levels could be considered stable when the samples were stored at 4 oC for 7 days. Our results revealed that under different conditions, calcium and phosphate levels are stable in saliva samples, and that freezing at -20oC is the storage condition of choice, allowing to accumulate a higher number of samples before analysis, making it suitable for routine and research assays.

Serum phosphorus is related to left ventricular remodeling independent of renal function in hospitalized patients with chronic kidney disease.

BACKGROUND: Increasing evidence indicated that phosphorus emerged as an important cardiovascular risk factor in patients with chronic kidney disease (CKD). The fact that serum phosphorus was closely linked to vascular and valvar calcification may account for one important reason. However, left ventricular remodeling may also serve as another potential mechanism of the cardiac toxicity of phosphorus. In the present study, we evaluated the association of serum phosphorus with left ventricular remodeling. METHODS: We investigated consecutive hospitalized patients with pre-dialysis CKD, who did not have symptomatic heart failure or take any phosphorus binder or calcitriol medications. Transthoracic echocardiography was applied to assess their left ventricular remodeling indices, both structural and functional. RESULTS: The 296 study subjects (mean age 56.4years) included 169 (57.1%) men, 203 (68.6%) hypertensive patients. In addition to gender, systolic blood pressure, and estimated glomerular filtration rate, serum phosphorus was an independent determinant of left ventricular mass index (LVMI, P=0.001). Similarly, serum phosphorus was also a determinant of left ventricular end diastolic dimension (P=0.0003), but not of relative wall thickness. In multivariate logistic analyses, serum phosphorus was significantly and independently associated with the prevalence of left ventricular hypertrophy (LVH, odds ratio [OR] 2.38 for each 1mmol/L increase, 95% CI 1.20-4.75, P=0.01). Moreover, the association was only confirmatory in eccentric LVH (OR 3.01, 95% CI 1.43-6.32, P=0.003) but not in concentric LVH (1.38, 95% CI, 0.54-3.49, P=0.50). CONCLUSION: Serum phosphorus was significantly and independently associated with LVMI and the prevalence of eccentric LVH in hospitalized patients with CKD.

Lamin A is involved in the development of vascular calcification induced by chronic kidney failure and phosphorus load.

Vascular calcification remains one of the main factors associated to morbidity and mortality in both ageing and chronic kidney disease. Both hyperphosphataemia, a well-known promoter of vascular calcification, and abnormal processing defects of lamin A/C have been associated to ageing. The main aim of this study was to analyse the effect of phosphorus load in the differential expression pattern of genes and proteins, particularly of lamin A/C, which are involved in phenotypic change of the vascular smooth muscle cells to osteoblast-like cells. The in vivo study of the calcified abdominal aortas from nephrectomized rats receiving a high phosphorus diet showed among others, a repression of muscle related proteins and overexpression of lamin A/C. Similar results were observed in vitro, where primary vascular smooth muscle cells cultured in calcifying medium showed increased expression of prelamin A and lamin A and abnormalities in the nuclear morphology. Co-immunoprecipitation assays showed novel and important physical interactions between lamin A and RUNX2 during the process of calcification. In fact, the knockdown of prelamin A and lamin A inhibited the increase of Runx2, osteocalcin and osteopontin gene expression, calcium deposition, nuclear abnormalities and the RUNX2 protein translocation into the nucleus of the cell. These in vivo and in vitro results highlight the important role played by lamin A in the process of vascular calcification.

Prevalence of Phosphorus-Based Additives in the Australian Food Supply: A Challenge for Dietary Education?

OBJECTIVE: Phosphorus-based food additives may pose a significant risk in chronic kidney disease given the link between hyperphosphatemia and cardiovascular disease. The objective of the study was to determine the prevalence of phosphorus-based food additives in best-selling processed grocery products and to establish how they were reported on food labels. DESIGN: A data set of 3000 best-selling grocery items in Australia across 15 food and beverage categories was obtained for the 12 months ending December 2013 produced by the Nielsen Company's Homescan database. The nutrition labels of the products were reviewed in store for phosphorus additives. The type of additive, total number of additives, and method of reporting (written out in words or as an E number) were recorded. MAIN OUTCOME MEASURES: Presence of phosphorus-based food additives, number of phosphorus-based food additives per product, and the reporting method of additives on product ingredient lists. RESULTS: Phosphorus-based additives were identified in 44% of food and beverages reviewed. Additives were particularly common in the categories of small goods (96%), bakery goods (93%), frozen meals (75%), prepared foods (70%), and biscuits (65%). A total of 19 different phosphorus additives were identified across the reviewed products. From the items containing phosphorus additives, there was a median (minimum-maximum) of 2 (1-7) additives per product. Additives by E number (81%) was the most common method of reporting. CONCLUSION: Phosphorus-based food additives are common in the Australian food supply. This suggests that prioritizing phosphorus additive education may be an important strategy in the dietary management of hyperphosphatemia. Further research to establish a database of food items containing phosphorus-based additives is warranted.

Effects of Dietary Calcium Supplementation on Bone Metabolism, Kidney Mineral Concentrations, and Kidney Function in Rats Fed a High-Phosphorus Diet.

We investigated the effects of dietary calcium (Ca) supplementation on bone metabolism, kidney mineral concentrations, and kidney function in rats fed a high-phosphorus (P) diet. Wistar strain rats were randomly divided into 4 dietary groups and fed their respective diets for 21 d: a diet containing 0.3% P and 0.5% Ca (C), a diet containing 1.5% P and 0.5% Ca (HP), a diet containing 0.3% P and 1.0% Ca (HCa), or a diet containing 1.5% P and 1.0% Ca (HPCa). Compared to the C group, the high-P diet increased serum parathyroid hormone concentration, markers of bone turnover, receptor activator of NF-κB ligand mRNA expression of the femur, kidney Ca and P concentrations, urinary N-acetyl-ß-D-glucosaminidase activity, and urinary ß2-microglobulin excretion, and decreased bone mineral content and bone mineral density of the femur and tibia. Dietary Ca supplementation improved the parameters of bone metabolism and kidney function in rats fed the high-P diet, while there were no significant differences in kidney Ca or P concentrations between the HP and HPCa groups. These results suggest that dietary Ca supplementation prevented the bone loss and decline in kidney function induced by a high-P diet, whereas dietary Ca supplementation did not affect kidney mineral concentrations in rats fed the high-P diet.

Correlates of anaemia in pregnant urban South Indian women: a possible role of dietary intake of nutrients that inhibit iron absorption.

OBJECTIVE: To identify correlates of anaemia during the first trimester of pregnancy among 366 urban South Indian pregnant women. DESIGN: Cross-sectional study evaluating demographic, socio-economic, anthropometric and dietary intake data on haematological outcomes. SETTING: A government maternity health-care centre catering predominantly to the needs of pregnant women from the lower socio-economic strata of urban Bangalore. SUBJECTS: Pregnant women (n 366) aged ≥18 and ≤40 years, who registered for antenatal screening at ≤14 weeks of gestation. RESULTS: Mean age was 22·6 (sd 3·4) years, mean BMI was 20·4 (sd 3·3) kg/m2 and 236 (64·5 %) of the pregnant women were primiparous. The prevalence of anaemia (Hb <11·0 g/dl) was 30·3 % and of microcytic anaemia (anaemia with mean corpuscular volume <80 fl) 20·2 %. Mean dietary intakes of energy, Ca, Fe and folate were well below the Indian RDA. In multivariable log-binomial regression analysis, anaemia was independently associated with high dietary intakes of Ca (relative risk; 95 % CI: 1·79; 1·16, 2·76) and P (1·96; 1·31, 2·96) and high intake of meat, fish and poultry (1·94; 1·29, 2·91). CONCLUSIONS: Low dietary intake of multiple micronutrients, but higher intakes of nutrients that inhibit Fe absorption such as Ca and P, may help explain high rates of maternal anaemia in India.

[The clinical and X-ray classification of osteonecrosis of the low jaw].

OBJECTIVE: To elaborate a clinical and X-ray classification of osteonecrosis of the low jaw in people with desomorphine or pervitin addiction. MATERIAL AND METHODS: Ninety-two patients with drug addiction who had undergone orthopantomography, direct frontal X-ray of the skull, and multislice computed tomography, followed by multiplanar and three-dimensional imaging reconstruction were examined. One hundred thirty four X-ray films and 74 computed tomographic images were analyzed. RESULTS: The authors proposed a clinical and X-ray classification of osteonecrosis of the low jaw in people with desomorphine or pervitin addiction and elaborated recommendations for surgical interventions on the basis of the developed classification. CONCLUSION: The developed clinical and X-ray classification and recommendations for surgical interventions may be used to treat osteonecroses of various etiology.

Análise de crescimento de Bixa orellana L. sob efeito da inoculação micorrízica e adubação fosfatada / Analyses of Bixa orellana L. growth under the effects of mycorrhizal inoculation and phosphate fertilization

Este estudo objetivou avaliar o desenvolvimento de Bixa orellana L. em condições de viveiro sob efeito da inoculação micorrízica e adubação fosfatada. As plantas foram cultivadas em sacos de polietileno com 0,18 X 0,30 m e capacidade de 1,3 kg de substrato. O delineamento experimental utilizado foi inteiramente casualizado com seis tratamentos e trinta repetições. As dosagens de fósforo utilizadas foram 0, 4.200 e 8.400 g m-3 de substrato. O fungo micorrízico arbuscular (FMA) da espécie Glomus clarum, foi utilizado em metade dos tratamentos (com e sem micorrizas) com inoculação de 2 g do fungo. As avaliações ocorreram 30, 60, 90 e 120 dias após a emergência das plântulas. Determinou-se a massa seca de folhas, área foliar, massa seca total, razão de área foliar, área foliar específica, taxa assimilatória líquida, taxa de crescimento relativo e taxa de crescimento absoluto. O fungo micorrízico facilita a absorção de fósforo pelo urucum, atendendo a sua exigência em relação ao nutriente. A dose de fósforo de 4.200 g m-3 em associação com FMA Glomus clarum ou 8.400 g m-3, com ou sem essa associação, são indicadas para o crescimento de plantas de urucum em viveiro, por promoverem adequadas respostas dos índices fisiológicos, contribuindo com seu desenvolvimento.

This study aimed to evaluate the development of Bixa orellana L. under nursery conditions and subjected to the effects of mycorrhizal inoculation and phosphate fertilization. The plants were grown in polyethylene bags with dimensions of 0.18 x 0.30 m and capacity of 1.3 kg substrate. The adopted experimental design was completely randomized with six treatments and thirty replicates. The used phosphorus levels were 0, 4.200 and 8.400 g m-3 substrate. The arbuscular mycorrhizal fungus (AMF) of the species Glomus clarum was used in half of the treatments (with and without mycorrhizae) with inoculation of 2 g of the fungus. Evaluations occurred at 30, 60, 90 and 120 days after the emergence of seedlings. Leaf dry mass, leaf area, total dry mass, leaf area ratio, specific leaf area, net assimilation rate, relative growth rate and absolute growth rate were determined. The mycorrhizal fungus facilitates phosphorus uptake by annatto, fulfilling its requirement for the nutrient. The phosphorus level of 4.200 g m-3 in association with Glomus clarum or 8.400 g m-3, with or without this association, are indicated for annatto plant growth in nurseries since they promote appropriate responses of physiological indexes, contributing to the plant development.

High phosphorus diet induces vascular calcification, a related decrease in bone mass and changes in the aortic gene expression.

In chronic kidney disease, hyperphosphatemia has been associated to vascular calcifications. Moreover, the rate and progression of vascular calcification have been related with the reduction of bone mass and osteoporotic fractures, hereby suggesting a strong link between vascular calcification and bone loss. Our aim was to prospectively study the effects of high phosphorus diet on bone mass, vascular calcification and gene expression profile of the arterial wall. A rat model of 7/8 nephrectomy fed with normal (0.6%) and moderately high (0.9%) phosphorus diet was used. Biochemical parameters, bone mineral density and vascular calcifications were assessed. A microarray analysis of the aortic tissue was also performed to investigate the gene expression profile. After 20 weeks, the rats fed with a high phosphorus diet showed a significant increase in serum phosphorus, PTH, and creatinine, together with aortic calcification and a decrease in bone mass. The histological analysis of the vascular calcifications showed areas with calcified tissue and the gene expression profile of this calcified tissue showed repression of muscle-related genes and overexpression of bone-related genes, among them, the secreted frizzled related proteins, well-known inhibitors of the Wnt pathway, involved in bone formation. The study demonstrated prospectively the inverse and direct relationship between vascular calcification and bone mass. In addition, the microarrays findings provide new information on the molecular mechanisms that may link this relationship.

Bisphosphonate-related osteonecrosis of the jaw (BRONJ): initial discovery and subsequent development.

The efficacy of bisphosphonates in controlling skeletally related events in cancer patients and fractures in osteoporotic patients coupled with a relatively low level of toxicity and adverse events resulted in a widespread use of these medications in oncology and general internal medicine. However, in early 2001 a relationship had been established between these medications and a new disease entity characterized by necrosis of bone that was isolated to the jaws. This paper will present the chronology of events that led to the discovery of this new complication now known as bisphosphonate-related osteonecrosis of the jaw and review the reaction of professional organizations, the pharmaceutical industry, and government regulators.

Uncovering the cause of "phossy jaw" Circa 1858 to 1906: oral and maxillofacial surgery closed case files-case closed.

The infamous "phossy jaw" that created an epidemic of exposed bone osteonecrosis exclusively in the jaws began around 1858 and continued until 1906, with only a few cases appearing since that time. This epidemic of osteonecrosis produced pain, swelling, debilitation, and a reported mortality of 20% and was linked to "yellow phosphorous," the key ingredient in "strike-anywhere" matches. In match-making factories, workers called "mixers," "dippers," and "boxers" were exposed to heated fumes containing this compound. Related to the duration of exposure, many of these workers developed painful exposed bone in the mouth, whereas their office-based counterparts did not. The exposed bone and clinical course were eerily similar to what modern day oral and maxillofacial surgeons see due to bisphosphonates used to treat metastatic cancer deposits in bone or osteoporosis. Although yellow phosphorus has a simple chemistry of P(4)O(10), when combined with H(2)O and CO(2) from respiration and with common amino acids, such as lysine, bisphosphonates almost identical to alendronate (Fosamax; Novartis Pharmaceuticals, East Hanover, NJ) and pamidronate (Aredia; Novartis Pharmaceuticals) result. Forensic evidence directly points to conversion of the yellow phosphorus in patients with "phossy jaw" to potent amino bisphosphonates by natural chemical reactions in the human body. Thus, the cause of phossy jaw in the late 1800s was actually bisphosphonate-induced osteonecrosis of the jaws, long before clever modern pharmaceutical chemists synthesized bisphosphonates. Today's bisphosphonate-induced osteonecrosis represents the second epidemic of "phossy jaw." Case closed.