Epidemiological study of kidney health in an area with high levels of soil cadmium and selenium: Does selenium protect against cadmium-induced kidney injury?

Chronic exposure to cadmium (Cd) can cause renal dysfunction. Studies of animals, cell cultures, and plants have found that selenium (Se) can effectively alleviate the hazard generated by Cd, but there has been little study of this in general human populations. This study recruited 313 subjects from China's Hubei Province, including 160 living in areas with high soil Cd and Se (exposure group) and 153 living in clean areas (control group). The levels of the following were detected: Cd and Se in blood (B-Cd and B-Se), urine (U-Cd and U-Se), and hair (H-Cd and H-Se); N-acetyl-ß-D-glucosaminidase (U-NAG), ß2-microglobulin (U-ß2-MG), and albumin (U-ALB) in urine; and malondialdehyde (S-MDA), superoxide dismutase (S-SOD), and glutathione peroxidase (S-GSH-Px) in serum. In addition, the interactions between Cd and Se were assessed. The median levels of B-Cd, B-Se, U-Cd, U-Se, H-Cd, H-Se, S-MDA, and S-GSH-Px of exposure group (2.60 ng/mL, 238.90 ng/mL, 3.13 µg/g Cr, 45.43 µg/g Cr, 0.06 µg/g, 0.70 µg/g, 5.22 nmol/mL, and 308.89 U, respectively) were significantly higher than of controls (0.95 ng/mL, 130.50 ng/mL, 1.08 µg/g Cr, 30.51 µg/g Cr, 0.04 µg/g, 0.49 µg/g, 4.71 nmol/mL, and 267.54 U, respectively), but there were no significant differences in U-NAG, U-ß2-MG, U-ALB, or S-SOD between the two groups. U-NAG levels were significantly negatively associated with the interaction between Cd and Se (B: -0.511, 95% CI: -0.886, -0.136). Additionally, changes in the direction of the estimated regression coefficient in the low and high H-Se groups were observed for U-Cd and S-MDA (from 0.018 to -0.090), U-Cd and S-GSH-Px (from -0.039 to 0.101). This study found that populations living in areas with high levels of soil Cd and Se did not show greater Cd-induced renal tubular and glomerular injuries than the control population, which could attribute to the protective effects of Se. The protective effects may be related to the peculiar function of Se that Se can combine with free Cd to activate the antioxidant enzyme system.

C. elegans expressing D76N ß2-microglobulin: a model for in vivo screening of drug candidates targeting amyloidosis.

The availability of a genetic model organism with which to study key molecular events underlying amyloidogenesis is crucial for elucidating the mechanism of the disease and the exploration of new therapeutic avenues. The natural human variant of ß2-microglobulin (D76N ß2-m) is associated with a fatal familial form of systemic amyloidosis. Hitherto, no animal model has been available for studying in vivo the pathogenicity of this protein. We have established a transgenic C. elegans line, expressing the human D76N ß2-m variant. Using the INVertebrate Automated Phenotyping Platform (INVAPP) and the algorithm Paragon, we were able to detect growth and motility impairment in D76N ß2-m expressing worms. We also demonstrated the specificity of the ß2-m variant in determining the pathological phenotype by rescuing the wild type phenotype when ß2-m expression was inhibited by RNA interference (RNAi). Using this model, we have confirmed the efficacy of doxycycline, an inhibitor of the aggregation of amyloidogenic proteins, in rescuing the phenotype. In future, this C. elegans model, in conjunction with the INVAPP/Paragon system, offers the prospect of high-throughput chemical screening in the search for new drug candidates.

An investigation into the effects of maternal supplementation with excess iodine on the mechanisms and impacts of reduced IgG absorption in the lamb postpartum.

An experiment was conducted to determine: (1) the effect of excess maternal I supplementation on the thyroid hormone status of the ewe and her progeny; (2) potential mechanisms underpinning the failure of passive transfer associated with excess I and (3) the growing lambs' response to natural gastrointestinal infection. Twin-bearing ewes received one of two treatments (n 32/treatment group): basal diet (C) or C plus 26·6 mg of iodine/ewe per d (I), supplied as calcium iodate. Ewes were individually fed from day 119 of gestation to parturition. Progeny of I ewes had lower (P<0·01) serum IgG concentrations from 24 h to 28 d postpartum but higher serum IgG concentrations at day 70 postpartum (P<0·05). I supplementation increased the relative expression of Fc receptor, IgA, IgM high affinity and polymeric Ig receptor in the ileum of the lamb at 24 h postpartum; however, thyroid hormone receptor-ß (THRB) and ß-2-microglobulin (B2M) expression declined (P<0·05). Progeny of I ewes had higher growth rates to weaning (P<0·05) and lower faecal egg count (FEC) for Nematodirus battus (P<0·05) between weeks 6 and 10 postpartum. In conclusion, excess maternal I supplementation negatively affected the thyroid hormone status, serum IgG concentration, ileal morphology and the gene expression of THRB and B2M in the ileum and ras-related protein (RAB) RAB25 and the mucin gene (MUC) MUC1 in the duodenum of the lamb postpartum. These effects were followed by an enhancement of average daily gain and lower N. battus FEC in the pre-weaning period of I-supplemented lambs.

Human kidney proximal tubule cells are vulnerable to the effects of Rauwolfia serpentina.

Rauwolfia serpentina (or Snake root plant) is a botanical dietary supplement marketed in the USA for maintaining blood pressure. Very few studies have addressed the safety of this herb, despite its wide availability to consumers. Its reported pleiotropic effects underscore the necessity for evaluating its safety. We used a human kidney cell line to investigate the possible negative effects of R. serpentina on the renal system in vitro, with a specific focus on the renal proximal tubules. We evaluated cellular and mitochondrial toxicity, along with a variety of other kidney-specific toxicology biomarkers. We found that R. serpentina was capable of producing highly detrimental effects in our in vitro renal cell system. These results suggest more studies are needed to investigate the safety of this dietary supplement in both kidney and other target organ systems.

Automated peritoneal dialysis prescriptions for enhancing sodium and fluid removal: a predictive analysis of optimized, patient-specific dwell times for the day period.

BACKGROUND: Remaining edema-free is a challenge for many automated peritoneal dialysis (APD) patients, especially those with fast ("high") transport characteristics. Although increased use of peritoneal dialysis (PD) solutions with high glucose concentrations may improve volume control, frequent use of such solutions is undesirable. METHODS: We used the 3-pore kinetic model to evaluate 4 alternative therapy prescriptions for the APD day exchange in anuric patients with high, high-average, and low-average transport characteristics. Four prescriptions were modeled: Therapy 1: Optimal, individualized dwell times with a dry period. Therapy 2: Use of a midday exchange. Therapy 3: Use of an icodextrin-containing dialysate during a 14-hour dwell. Therapy 4: Use of optimal, individualized dwell times, followed by an icodextrin dwell to complete the daytime period. The alternative therapies were compared with a reference standard therapy using glucose solution during a 14-hour dwell. The nighttime prescription was identical in all cases (10 L over 10 hours), and all glucose solutions contained 2.27% glucose. Net ultrafiltration (UF), sodium removal (NaR), total carbohydrate (CHO) absorption, and weekly urea Kt/V for a 24-hour period were computed and compared. RESULTS: The UF and NaR were substantially higher with therapy 1 than with standard therapy (1034 mL vs 621 mL and 96 mmol vs 51 mmol respectively), without significant changes in CHO absorption or urea Kt/V. However, therapy 1 resulted in reduced ß2-microglobulin clearance (0.74 mL/min vs 0.89 mL/min with standard therapy). Compared with therapy 1, therapy 2 improved UF and NaR (1062 mL vs 1034 mL and 99 mmol vs 96 mmol); however, that improvement is likely not clinically significant. Therapy 2 also resulted in a higher Kt/V (2.07 vs 1.72), but at the expense of higher glucose absorption (difference: 42 g). The UF and NaR were highest with a long icodextrin-containing daytime dwell either preceded by a short optimized dwell (1426 mL and 155 mmol) or without such a dwell (1327 mL and 148 mmol). CONCLUSIONS: The 3-pore model predictions revealed that patient-specific optimal dwell times and regimens with a longer day dwell might provide improved UF and NaR options in APD patients with a variety of peritoneal membrane transport characteristics. In patients without access to icodextrin, therapy 1 might enhance UF and NaR and provide a short-term option to increase fluid removal. Although that approach may offer clinicians a therapeutic option for the overhydrated patient who requires increased UF in the short term, APD prescriptions including icodextrin provide a means to augment sodium and fluid removal. Data from clinical trials are needed to confirm the predictions from this study.

[Clinical results of convective therapies]. / Risultati clinici delle terapie convettive secondo l'EBM.

Convective therapies can be a good additional option in extracorporeal renal replacement therapy, but so far the clinical evidence in their favor is rather scarce. In this review the results of the most important studies are discussed, grouped by main outcomes: intradialytic cardiovascular stability, beta2-microglobulin, mortality, calcium-phosphorus metabolism, and possible effect on anemia. In general, the use of convective therapies for reimbursement reasons but without any clear clinical benefit is not justified. The fractional division of convective therapies into various subtypes and the use of different levels of convection among centers make their widespread clinical implementation unlikely in the near future. No firm conclusions can be drawn right now and more controlled clinical trials on convective therapies will be needed to clarify their role in renal replacement therapy.

Copper-trafficking efficacy of copper-pyruvaldehyde bis(N4- methylthiosemicarbazone) on the macular mouse, an animal model of Menkes disease.

BACKGROUND: Menkes disease (MD) is a disorder of copper transport caused by ATP7A mutations. Although parenteral copper supplements are partly effective in treating MD, the copper level in the brain remains insufficient, whereas copper accumulates in the kidney. We investigated the copper-trafficking efficacy of copper-pyruvaldehyde bis(N4-methylthiosemicarbazone) (Cu-PTSM), a lipophilic copper complex, in macular mice, an animal model of MD. METHODS: Macular mice were treated with cupric chloride (CuCl2) or Cu-PTSM on postnatal days 4, 10, and 17. At 4 wk of age, the copper levels in major organs and cytochrome oxidase (CO) activity in brain tissue were measured. Hematology, blood biochemistry, and urinary ß2-microglobulin (ß2-M) secretion were also assessed. RESULTS: The copper levels in the brains of the Cu-PTSM-treated group remained low, but CO activity in the cerebral and cerebellar cortices in the Cu-PTSM-treated group were higher than those in the CuCl2-treated group. There were no significant differences in hematological or biochemical findings or in urinary ß2-M secretion among the groups. CONCLUSION: Although the copper-trafficking efficacy of Cu-PTSM was limited, the improved CO activity in the brain suggests that Cu-PTSM delivered copper more effectively to neuronal CO than did CuCl2. Reduced renal copper accumulation may be beneficial in prolonged copper supplementation.

Loss of class I MHC function alters behavior and stress reactivity.

The importance of the classical immune molecule, class I major histocompatibility complex to central nervous system function is one of the most surprising discoveries related to neuroimmunology in the past decade. Mice lacking both ß-2microglobulin and transporter associated with antigen processing (ß2M-/-TAP-/-) showed differences in basal behavior. In response to saline injection, ß2M-/-TAP-/- mice showed a significant hypothalamic pituitary adrenal activation that was not observed in wild type mice, while lipopolysaccharide-induced cytokine expression in the hypothalamus was similar in ß2M-/-TAP-/- and wild type mice. Overall, these data show that class I MHC plays an important role in behavior and stress reactivity.

Vaccine-induced antibodies linked to bovine neonatal pancytopenia (BNP) recognize cattle major histocompatibility complex class I (MHC I).

A mysterious disease affecting calves, named bovine neonatal pancytopenia (BNP), emerged in 2007 in several European countries. Epidemiological studies revealed a connection between BNP and vaccination with an inactivated vaccine against bovine virus diarrhea (BVD). Alloantibodies reacting with blood leukocytes of calves were detected in serum and colostrum of dams, which have given birth to calves affected by BNP. To understand the linkage between vaccination and the development of alloantibodies, we determined the antigens reacting with these alloantibodies. Immunoprecipitation of surface proteins from bovine leukocytes and kidney cells using sera from dams with a confirmed case of BNP in their gestation history reacted with two dominant protein species of 44 and 12 kDa. These proteins were not detected by sera from dams, free of BVDV and not vaccinated against BVD, and from sera of animals vaccinated with a different inactivated BVD vaccine. The 44 kDa protein was identified by mass spectrometry analysis as MHC I, the other as ß-2-microglobulin. The presence of major histocompatibility complex class I (MHC I) in the vaccine was confirmed by Western blot using a MHC I specific monoclonal antibody. A model of BNP pathogenesis is proposed.

Effect of Cordyceps sinensis on renal function of patients with chronic allograft nephropathy.

OBJECTIVE: To investigate the effect of Cordyceps sinensis (Bailing capsule, fermented agent of C. sinensis) on renal function of patients with chronic allograft nephropathy (CAN). METHODS: A total of 231 CAN patients who underwent transplantation between 2005 and 2008 and experienced chronic graft dysfunction were randomly divided into 2 groups. Patients in group A (n = 122) were treated with immunosuppressive agents and C. sinensis (2.0 g/day, 3 times a day), while patients in group B (n = 109) were treated with traditional immunosuppressive drugs. Serum creatinine (SCr), blood urea nitrogen (BUN), creatinine clearance rate (C(Cr)) and urinary protein in 24 h (24-hour Upro) of all patients were measured before and after treatment. Urinary concentrations of transforming growth factor (TGF)-ß(1), retinol-binding protein (RBP) and ß(2)-microglobulin (ß(2)-MG) were detected at the same time. RESULTS: After 6-month treatment with C. sinensis, SCr and C(Cr) in group A were significantly improved (p < 0.05), while there was no significant improvement observed for group B. There was no significant change in BUN in groups A and B (p > 0.05). 24-hour Upro, RBP and ß(2)-MG were lower in group A after treatment with C. sinensis (p < 0.05 or p < 0.01), and urinary TGF-ß(1) in group A was significantly lower than the values before C. sinensis treatment (p < 0.05), but showed no change in patients of group B. In group A, renal function had improved in 72 cases, stabilized in 38 cases, and worsened in 12 cases. In group B, renal function had improved in 14 cases, stabilized in 50 cases, and worsened in 45 cases (p < 0.05). CONCLUSION: C. sinensis therapy is advantageous in improving renal function of CAN patients by retarding CAN progression.

Effect of tetracyclines on the dynamics of formation and destructuration of beta2-microglobulin amyloid fibrils.

The discovery of methods suitable for the conversion in vitro of native proteins into amyloid fibrils has shed light on the molecular basis of amyloidosis and has provided fundamental tools for drug discovery. We have studied the capacity of a small library of tetracycline analogues to modulate the formation or destructuration of ß2-microglobulin fibrils. The inhibition of fibrillogenesis of the wild type protein was first established in the presence of 20% trifluoroethanol and confirmed under a more physiologic environment including heparin and collagen. The latter conditions were also used to study the highly amyloidogenic variant, P32G. The NMR analysis showed that doxycycline inhibits ß2-microglobulin self-association and stabilizes the native-like species through fast exchange interactions involving specific regions of the protein. Cell viability assays demonstrated that the drug abolishes the natural cytotoxic activity of soluble ß2-microglobulin, further strengthening a possible in vivo therapeutic exploitation of this drug. Doxycycline can disassemble preformed fibrils, but the IC(50) is 5-fold higher than that necessary for the inhibition of fibrillogenesis. Fibril destructuration is a dynamic and time-dependent process characterized by the early formation of cytotoxic protein aggregates that, in a few hours, convert into non-toxic insoluble material. The efficacy of doxycycline as a drug against dialysis-related amyloidosis would benefit from the ability of the drug to accumulate just in the skeletal system where amyloid is formed. In these tissues, the doxycycline concentration reaches values several folds higher than those resulting in inhibition of amyloidogenesis and amyloid destructuration in vitro.

[Effect of Astragalus and Salvia's effective components and their compatibility on JAK/STAT pathway].

OBJECTIVE: To study the effect of Astragalus and Salvia's effective components and their compatibility on JAK/STAT pathway of rats' renal fibrosis. METHODS: 66 SD rats were randomly divided into 7 groups: normal group,model group,fosinopril group, salvianolic acids group, astragalus saponins group, granules compatibility of Astragalus and Salvia group, components combination of Astragalus and Salvia group. The variation of beta2-microglobulin(beta2-MG), the changes of renal pathology and JAK/STAT pathway were observed. RESULTS: The changes in renal pathology of treatment groups had different degrees of improvement; Astragalus and Salvia could reduce the urinary beta2-MG of unilateral ureteral obstruction (UUO) rat (P < 0.05), which was equal with fosinopril group. The rest of the treatment groups decreased especially fosinopril group while the difference was not significant when compared with the model group. Astragalus and its effective components could reduce the expression of renal tissue JAK, STAT1, STAT3 protein, among which fosinopril group and granules compatibility of Astragalus decreased significantly. Astragalus saponins group was not obvious, and the rest of the treatment group had significantly minor effect. CONCLUSION: Astragalus and Salvia's effective components and their compatibility may protect renal tubular function in unilateral ureteral obstruction, which may interfere with UUO rat kidney with JAK/STAT signaling pathway.

Screening of fibrillogenesis inhibitors of ß2-microglobulin: integrated strategies by mass spectrometry capillary electrophoresis and in silico simulations.

The challenging search of ligands for the amyloidogenic protein ß(2)-microglobulin led us to set up an integrated strategy that combines analytical techniques and molecular modelling. Using a chemical library composed of 90 sulphonated molecules and a novel MS screening approach, we initially single out a few new binders. To check for anti-amyloid activity, the best hit obtained was thoroughly studied by docking analysis, affinity and refolding experiments by capillary electrophoresis and in vitro fibrillogenesis Thioflavin T test. Correlative analysis of the overall results obtained from the MS screening led to develop an equation able to identify the key factors of the affinity for ß(2)-microglobulin and to predict the affinity for novel derivatives. The proposed equation was then used for a virtual screening of a large compound database. Studies on the new hit thus retrieved confirm the predictive potential of both the equation on affinity and of docking analysis on anti-amyloid activity.

Structure of the preamyloid dimer of beta-2-microglobulin from covalent labeling and mass spectrometry.

Beta-2-microglobulin (beta2m) self-associates into fibrillar amyloid deposits in the musculoskeletal system of patients undergoing hemodialysis treatment. Previous studies have shown that stoichiometric amounts of Cu(II) at near physiological conditions can cause beta2m to organize into native-like dimers prior to forming amyloid fibrils. Here, we report the results from selective covalent labeling reactions combined with mass spectrometry that provide insight into the amino acid residues that mediate dimer formation in the wild-type protein. Using three complementary covalent labeling reagents, we find that the dimer interface is formed by the antiparallel stacking of ABED beta-sheets from two beta2m monomers. In addition, our data clearly indicate that a dimer interface involving the interactions of D-D strands from separate protein units as seen in the recent crystal structures of two mutant beta2m oligomers is unlikely.

Solute kinetics with short-daily home hemodialysis using slow dialysate flow rate.

"NxStage System One()" is increasingly used for daily home hemodialysis. The ultrapure dialysate volumes are typically between 15 L and 30 L per dialysis, substantially smaller than the volumes used in conventional dialysis. In this study, the impact of the use of low dialysate volumes on the removal rates of solutes of different molecular weights and volumes of distribution was evaluated. Serum measurements before and after dialysis and total dialysate collection were performed over 30 times in 5 functionally anephric patients undergoing short-daily home hemodialysis (6 d/wk) over the course of 8 to 16 months. Measured solutes included beta(2) microglobulin (beta(2)M), phosphorus, urea nitrogen, and potassium. The average spent dialysate volume (dialysate plus ultrafiltrate) was 25.4+/-4.7 L and the dialysis duration was 175+/-15 min. beta(2) microglobulin clearance of the polyethersulfone dialyzer averaged 53+/-14 mL/min. Total beta(2)M recovered in the dialysate was 106+/-42 mg per treatment (n=38). Predialysis serum beta(2)M levels remained stable over the observation period. Phosphorus removal averaged 694+/-343 mg per treatment with a mean predialysis serum phosphorus of 5.2+/-1.8 mg/dL (n=34). Standard Kt/V averaged 2.5+/-0.3 per week and correlated with the dialysate-based weekly Kt/V. Weekly beta(2)M, phosphorus, and urea nitrogen removal in patients dialyzing 6 d/wk with these relatively low dialysate volumes compared favorably with values published for thrice weekly conventional and with short-daily hemodialysis performed with machines using much higher dialysate flow rates. Results of the present study were achieved, however, with an average of 17.5 hours of dialysis per week.

A beta2-microglobulin cleavage variant fibrillates at near-physiological pH.

Beta2-microglobulin (beta2m) deposits as amyloid in dialysis-related amyloidosis (DRA), predominantly in joints. The molecular mechanisms underlying the amyloidogenicity of beta2m are still largely unknown. In vitro, acidic conditions, pH < 4.5, induce amyloid fibrillation of native beta2m within several days. Here, we show that amyloid fibrils are generated in less than an hour when a cleavage variant of beta2m--found in the circulation of many dialysis patients--is exposed to pH levels (pH 6.6) occurring in joints during inflammation. Aggregation and fibrillation, including seeding effects with intact, native beta2m were studied by Thioflavin T fluorescence spectroscopy, turbidimetry, capillary electrophoresis, and electron microscopy. We conclude that a biologically relevant variant of beta2m is amyloidogenic at slightly acidic pH. Also, only a very small amount of preformed fibrils of this variant is required to induce fibrillation of native beta2m. This may explain the apparent lack of detectable amounts of the variant beta2m in extracts of amyloid from DRA patients.

Capillary electrophoresis in drug discovery.

The several advantages that capillary electrophoresis (CE) offers in the study of protein folding, protein-ligand and protein-protein interactions, render this methodology appealing in several areas. In this chapter, a specific example is reported, where the use of affinity CE (ACE) in drug discovery is particularly advantageous over other separative and spectroscopic techniques. ACE is an analytical approach in which the migration patterns of interacting molecules in an electric field are recorded and used to identify specific binding and to estimate binding constants. A library of compounds has been tested, in free solution and with minimum sample consumption, for the affinity to two targets previously separated by CE, the native form and the partially structured intermediate of the folding of beta(2)-microglobulin (beta(2)-m) [Chiti et al. (J. Biol. Chem. 276:46714-46721, 2001), Quaglia et al. (Electrophoresis 26:4055-4063, 2005)]. beta(2)-m is an intrinsically amyloidogenic protein, and its tendency to misfold is responsible for dialysis-related amyloidosis, an unavoidable complication of chronic haemodialysed patients. The criteria for choosing the compounds to be screened, the method conditions, and the possible data analysis strategies are detailed and discussed in this chapter.

Effect of on-line hemodiafiltration with endogenous reinfusion (HFR) on the calcium-phosphorus metabolism: medium-term effects.

AIM: The purpose of the study was to examine the effect of hemodiafiltration with endogenous reinfusion (HFR) compared to hemodialysis (HD) on 28 uremic patients with secondary hyperparathyroidism (2HPT) but positively selected for good and stable control of phosphatemia in order to evaluate the independent effects of dialysis treatments on bone turnover metabolism. METHODS: The study was divided into 3 periods of observation: a) HD for three months; b) HFR for three months; c) HFR for a further 3 months. We analysed the trend of: whole PTH, 1-84 PTH, 7-84 PTH, alkaline phosphatase and its bone isoenzyme, total and ionised calcium, phosphatemia, dose of phosphate binder agents, beta2-microglobulin, CRP. All the variations found were evaluated through mean values +/- SD, t-tests, multivariate analysis. RESULTS: We observed a deceleration in bone turnover characterized by a reduction of the total and bone alkaline phosphatase (IU/mL) from 92.3 +/- 82.8 and 35.8 +/- 49.8 at the end of HD to 63.4 +/- 23.9 and 16.0 +/- 8.7 at the end of HFR, respectively, and 1-84 PTH from 317.5 +/- 264.6 pg/mL at the end of HD to 287.5 +/- 258.9 pg/mL at the end of the 3rd month of HFR. Beta2-microglobulin was reduced from 32.9 +/- 16.1 mg/L at the end of HD to 26.4 +/- 8.1 mg/L already at the end of the first three months of HFR. CRP was reduced from 2.5 +/- 2.6 mg/dL at the beginning of the study to 1.3 +/- 1.7 mg/dL at the end of HFR. There were no differences with regard to: dialytic efficiency, nutritional status, calcemia, phosphatemia (maintained in the K-DOQI range for the entire duration of the study), also thanks to more careful use of phosphate chelating agents. CONCLUSION: We are of the opinion that HFR - essentially thanks to the use of ultrapure endogenous infusate - induces a deceleration in bone turnover due to 2PHT. In addition, phosphate subtraction in HFR is better compared to HD, thanks to the improvement of the anti-inflammatory conditions by removing the cytokines harmful to bone metabolism and excluding a priori the negative effects related to hyperphosphatemia.