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1.
Ren Fail ; 41(1): 636-643, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31269846

RESUMO

Background: Mineral and bone disorder (MBD) in hemodialysis patients is associated with increased morbidity and mortality. Studies on the MBD status of hemodialysis patients at high altitudes are extremely limited. Methods: A total of 146 hemodialysis patients from 5 local hospitals across all districts with hemodialysis centers in the Tibetan Plateau were enrolled in this cross-sectional study. Parameters related to MBD, including serum phosphorus (P), calcium (Ca), and intact parathyroid hormone (iPTH) levels, were measured. The achievement of MBD goals was compared with the achievement in the Dialysis Outcomes and Practice Study (DOPPS) 3, DOPPS 4 and a multicenter study of MBD in China. Factors associated with hyperphosphatemia were examined. Results: Altogether, 146 hemodialysis patients were recruited from the Tibetan Plateau. According to the K/DIGO guidelines, there were low achievement rates for serum Ca (40.4%), P (29.7%), and iPTH (47.1%). As for the (KDOQI) guidelines, the rates of achievement of defined targets were 38.4%, 33.7% and 16.4% for serum Ca, P and iPTH, respectively. The percentages of patients reaching the KDOQI targets for corrected Ca, P, and iPTH were significantly lower for Tibetan patients than the percentages found in DOPPS 3 (38.4% vs. 50.4%, 33.7% vs. 49.8%, and 16.4% vs. 31.4%, respectively, all p < .001) and DOPPS 4 (38.4% vs. 56.0%, 33.7% vs. 54.5%, and 16.4% vs. 35.3%, respectively, all p < .001). The percentage of patients reaching the KDOQI targets for iPTH was significantly lower in Tibet than in the plain areas of China (16.4% vs. 26.5%, p < .001). The proportion of patients with hypocalcemia was higher in Tibet than in the plain areas (44.5% vs. 19.4%, p < .001). The percentage of local patients with optimal P was significantly higher for patients with an activated vitamin D prescription than for patients without an activated vitamin D prescription (45.3% vs. 19.3%, p < .001). Age and the activated vitamin D prescription were independently associated with hyperphosphatemia. Conclusion: The MBD status of hemodialysis patients in Tibet is far from the ideal level. High altitude is one of the possible causes of the differences found, but not the principal one. It is necessary for medical staff in Tibet to improve the detection and treatment of MBD.


Assuntos
Distúrbio Mineral e Ósseo na Doença Renal Crônica/diagnóstico , Hiperfosfatemia/diagnóstico , Diálise Renal/efeitos adversos , Insuficiência Renal Crônica/terapia , Adulto , Cálcio/sangue , Distúrbio Mineral e Ósseo na Doença Renal Crônica/sangue , Estudos Transversais , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Hormônio Paratireóideo/sangue , Fósforo/sangue , Tibet , Vitamina D/administração & dosagem
2.
Pediatr Nephrol ; 34(1): 107-115, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30267239

RESUMO

BACKGROUND: Studies in healthy pediatric populations and adults treated with dialysis demonstrate higher parathyroid hormone (PTH) and lower 25-hydroxyvitamin D levels in African-Americans. Despite these findings, African-Americans on dialysis demonstrate greater bone strength and a decreased risk of fracture compared to the Caucasian dialysis population. The presence of such differences in children and young adult dialysis patients is unknown. METHODS: Differences in the markers of mineral and bone metabolism (MBM) were assessed in 661 incident dialysis patients (aged 1 month to < 21 years). Racial-ethnic differences in PTH, calcium, phosphate, and total alkaline phosphatase (AP) activity were analyzed over the first year of dialysis using multivariate linear mixed models. RESULTS: African-American race predicted 23% higher serum PTH (95% CI, 4.7-41.3%) when compared to Caucasian patients, while Hispanic ethnicity predicted 17.5% higher PTH (95% CI, 2.3-38%). Upon gender stratification, the differences in PTH were magnified in African-American and Hispanic females: 38% (95% CI, 14.8-69.8%) and 28.8% (95% CI, 4.7-54.9%) higher PTH compared to Caucasian females. Despite higher PTH values, African-American females persistently demonstrated up to 10.9% lower serum AP activity (95% CI, - 20.6-- 0.7%). CONCLUSIONS: There are racial-ethnic differences in the markers of MBM. Higher PTH is seen in African-American and Hispanic children and young adults on dialysis with a magnification of this difference amongst the female population. There is a need to consider how factors like race, ethnicity, and gender impact the goal-targeted treatment of MBM disorders.


Assuntos
Distúrbio Mineral e Ósseo na Doença Renal Crônica/epidemiologia , Disparidades nos Níveis de Saúde , Falência Renal Crônica/terapia , Hormônio Paratireóideo/sangue , Diálise Renal/efeitos adversos , Adolescente , Afro-Americanos/estatística & dados numéricos , Biomarcadores/sangue , Criança , Pré-Escolar , Distúrbio Mineral e Ósseo na Doença Renal Crônica/sangue , Distúrbio Mineral e Ósseo na Doença Renal Crônica/diagnóstico , Distúrbio Mineral e Ósseo na Doença Renal Crônica/etiologia , Estudos de Coortes , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Hispano-Americanos/estatística & dados numéricos , Humanos , Incidência , Falência Renal Crônica/sangue , Falência Renal Crônica/complicações , Masculino , Fatores de Risco , Vitamina D/análogos & derivados , Vitamina D/sangue , Adulto Jovem
3.
Nephrol Dial Transplant ; 34(4): 682-691, 2019 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-30165528

RESUMO

BACKGROUND: The clinical management of chronic kidney disease-mineral bone disorder (CKD-MBD) remains extremely challenging, partially due to difficulties in defining high-risk phenotypes based on serum biomarkers. We evaluated the prevalence and outcomes of 27 mutually exclusive CKD-MBD phenotypes in a large, multi-national cohort of chronic dialysis patients over a 5-year follow-up study. METHODS: In this historical cohort study, we enrolled all haemodialysis patients registered in EuCliD® on 1 July 2011 across 28 Europe, the Middle East and Africa (EMEA) and South American countries. We created 27 mutually exclusive phenotypes based on combinations of serum parathyroid hormone (PTH), phosphorus (P) and calcium (Ca) 6-month averages (L, low; T, target; H, high). We tested the association between CKD-MBD phenotypes and 5-year mortality and hospitalization risk by outcome risk score-adjusted proportional hazard regression. RESULTS: We enrolled 35 721 eligible patients. Eastern European and South American countries generally achieved poorer CKD-MBD control when compared with Western European countries (prevalence ratio: 0.79; P < 0.001). There were 15 795 deaths [126.7 deaths/1000 person-years; 95% confidence interval (CI) 124.7-128.7]; 18 014 had at least one hospitalization (203.9 hospitalizations/1000 person-years; 95% CI 201.0-206.9); the incidence of the composite endpoint was 280.0 events/1000 person-years (95% CI 276.6-283.5). In the fully adjusted model, relative mortality risk ranged from hazard ratio (HR) = 1.07 (PTH/Ca/P: TLT) to HR = 1.59 (PTH/Ca/P: LTL), whereas the relative composite endpoint risk ranged from HR = 1.07 (PTH/Ca/P: TTH) to HR = 1.36 (PTH/Ca/P: LTL). CONCLUSION: We identified several CKD-MBD phenotypes associated with reduced hospitalization-free survival and increased mortality. Ranking of relative risk estimates or excess events concurs in informing healthcare priority setting.


Assuntos
Biomarcadores/sangue , Cálcio/sangue , Distúrbio Mineral e Ósseo na Doença Renal Crônica/diagnóstico , Hospitalização/estatística & dados numéricos , Hormônio Paratireóideo/sangue , Fosfatos/sangue , Diálise Renal/mortalidade , Idoso , Distúrbio Mineral e Ósseo na Doença Renal Crônica/sangue , Distúrbio Mineral e Ósseo na Doença Renal Crônica/mortalidade , Estudos de Coortes , Feminino , Seguimentos , Humanos , Agências Internacionais , Masculino , Pessoa de Meia-Idade , Prognóstico , Taxa de Sobrevida
4.
Saudi J Kidney Dis Transpl ; 29(6): 1506-1510, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30588988

RESUMO

Periarticular calcification is a frequent radiographic manifestation in chronic kidney disease (CKD). However, clinical presentation as inflammatory periarthritis, tenosynovitis, and bursitis is unusual. A 34-year-old man with CKD on dialysis for three years presented with painful swollen joints. His adherence to regular dialysis, phosphate binders, Vitamin D supplements, and antihypertension therapy was poor. He had swelling of the right thumb, index, and little fingers; periarticular swelling of the left middle finger and right little toe; and extensor tenosynovitis of the wrists and right olecranon bursitis. Laboratory investigations showed the following: urea 36 mmol/L; creatinine 1764 umol/L; serum urate 0.37 mmol/L; corrected calcium 1.76 mmol/L; phosphate 4.32 mmol/L; 25-dihydroxycholecalciferol 30 ng/mL; and parathyroid hormone 104 pmol/L. Radiographs showed periarticular calcification corresponding to the sites of inflammation. The inflammation resolved with oral steroids. In our patient, deranged mineral and bone metabolism contributed to periarticular calcification at multiple sites, mimicking inflammatory polyarthritis.


Assuntos
Artrite/diagnóstico por imagem , Calcinose/diagnóstico por imagem , Distúrbio Mineral e Ósseo na Doença Renal Crônica/etiologia , Articulações dos Dedos/diagnóstico por imagem , Insuficiência Renal Crônica/complicações , Articulação do Dedo do Pé/diagnóstico por imagem , Adulto , Calcinose/etiologia , Calcinose/terapia , Distúrbio Mineral e Ósseo na Doença Renal Crônica/diagnóstico , Distúrbio Mineral e Ósseo na Doença Renal Crônica/terapia , Diagnóstico Diferencial , Humanos , Masculino , Valor Preditivo dos Testes , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/terapia
5.
Rev Med Suisse ; 14(626): 2012-2017, 2018 Nov 07.
Artigo em Francês | MEDLINE | ID: mdl-30422421

RESUMO

The management of osteoporosis in patients with mild to moderate chronic kidney disease (CKD) can be established as in general population. In severe or terminal CKD, bone densitometry is indicated. Bone-specific alkaline phosphatase is considered a useful marker for distinguishing among the histologic types of renal osteodystrophy. In ambiguous cases, bone biopsy together with quantitative histomorphometry will be necessary. As far as the treatment is concerned, the bisphosphonates, which had been avoided due to their renal excretion as well as the official warnings against using them in case of renal clearance lower than 30 ml/min, seem to be effective even in advanced stages of renal disease. There are limited data, though, regarding the management of osteoporosis in terminal stages of CKD.


Assuntos
Distúrbio Mineral e Ósseo na Doença Renal Crônica , Falência Renal Crônica , Osteoporose , Insuficiência Renal Crônica , Biópsia , Osso e Ossos/patologia , Distúrbio Mineral e Ósseo na Doença Renal Crônica/diagnóstico , Distúrbio Mineral e Ósseo na Doença Renal Crônica/terapia , Humanos , Falência Renal Crônica/complicações , Osteoporose/diagnóstico , Osteoporose/etiologia , Osteoporose/terapia
6.
J Pediatr ; 202: 171-178.e3, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30268401

RESUMO

OBJECTIVE: We sought to assess worldwide differences among pediatric patients undergoing hemodialysis. Because practices differ widely regarding nutritional resources, treatment practice, and access to renal replacement therapy, investigators from the Pediatric Investigation and Close Collaboration to examine Ongoing Life Outcomes, the pediatric subset of the MONitoring Dialysis Outcomes Cohort (PICCOLO MONDO) performed this cross-sectional study. We hypothesized that growth would be better in developed countries, possibly at the expense of bone mineral disease. STUDY DESIGN: In this cross-sectional study, we analyzed growth by height z score and recommended age-specific bone mineral metabolism markers from 225 patients <18 years of age maintained on hemodialysis, between the years of 2000 to 2012 from 21 countries in different regions. RESULTS: The patients' median age was 16 (IQR 14-17) years, and 45% were females. A height z score less than the third percentile was noted in 34% of the cohort, whereas >66% of patients reported normal heights, with patients from North America having the greatest proportion (>80%). More than 70% of the entire cohort had greater than the age-recommended levels of phosphorus, particularly in the Asia-Pacific and North America, where we also observed the greatest body mass index z score (0.99 ± 1.6) and parathyroid hormone levels (557.1 [268.4-740.5]). Below-recommended parathyroid hormone levels were noted in 26% and elevated levels in 61% of the entire sample, particularly in the Asia Pacific region. Lower-than-recommended calcium levels were noted in 36% of the entire cohort, particularly in Latin America. CONCLUSIONS: We found regional differences in growth- and age-adjusted bone mineral metabolism markers. Children from North America had the best growth, received the most dialysis, but also had the worst phosphate control and body mass index z scores.


Assuntos
Estatura , Doenças Ósseas Metabólicas/epidemiologia , Distúrbio Mineral e Ósseo na Doença Renal Crônica/epidemiologia , Falência Renal Crônica/epidemiologia , Falência Renal Crônica/terapia , Diálise Renal/métodos , Adolescente , Antropometria , Biomarcadores/sangue , Índice de Massa Corporal , Doenças Ósseas Metabólicas/diagnóstico , Criança , Pré-Escolar , Distúrbio Mineral e Ósseo na Doença Renal Crônica/diagnóstico , Estudos Transversais , Feminino , Saúde Global , Humanos , Internacionalidade , Falência Renal Crônica/diagnóstico , Masculino , Prognóstico , Medição de Risco , Taxa de Sobrevida
7.
Nefrología (Madrid) ; 38(5): 476-490, sept.-oct. 2018. graf, ilus, tab
Artigo em Espanhol | IBECS | ID: ibc-177633

RESUMO

Osteoporosis (OP) y enfermedad renal crónica (ERC) influyen de manera independiente en la salud ósea y cardiovascular. Un número significativo de pacientes con ERC, especialmente desde estadios 3a a 5D, presentan una disminución significativa de la densidad mineral ósea condicionando un alto riesgo de fractura y un incremento importante de la morbimortalidad asociada. Independientemente de la OP clásica asociada a edad y/o sexo, las propiedades mecánicas del hueso se encuentran afectadas adicionalmente por factores intrínsecos a la ERC ("OP urémica"). En la primera parte de esta revisión, analizaremos conceptos generales sobre densidad mineral ósea, OP y fracturas, en gran parte infravalorados hasta ahora por los nefrólogos debido a la falta de evidencias y a las dificultades diagnósticas en el contexto de la ERC. Actualmente se ha demostrado que una densidad mineral ósea disminuida es realmente predictiva del riesgo de fracturas en pacientes con ERC, aunque no permite distinguir entre las causas que la originan (hiperparatiroidismo, enfermedad adinámica del hueso y/o osteoporosis senil, etc.). Por ello, en la segunda parte analizaremos las implicaciones terapéuticas en distintos estadios de la ERC. En cualquier caso, la valoración individualizada de los factores mayores y menores del riesgo de fractura, la cuantificación de dicho riesgo (i.e. con el uso de herramientas como el FRAX(R)) y las indicaciones potenciales de densitometría en pacientes con ERC podrían constituir un primer paso importante en espera de nuevas guías clínicas basadas en estudios aleatorizados que no excluyan a pacientes con ERC, evitando mientras tanto nihilismo terapéutico en un área de creciente importancia


Osteoporosis (OP) and chronic kidney disease (CKD) independently influence bone and cardiovascular health. A considerable number of patients with CKD, especially those with stages 3a to 5D, have a significantly reduced bone mineral density leading to a high risk of fracture and a significant increase in associated morbidity and mortality. Independently of classic OP related to age and/or gender, the mechanical properties of bone are also affected by inherent risk factors for CKD ("uraemic OP"). In the first part of this review, we will analyse the general concepts regarding bone mineral density, OP and fractures, which have been largely undervalued until now by nephrologists due to the lack of evidence and diagnostic difficulties in the context of CKD. It has now been proven that a reduced bone mineral density is highly predictive of fracture risk in CKD patients, although it does not allow a distinction to be made between the causes which generate it (hyperparathyroidism, adynamic bone disease and/or senile osteoporosis, etc.). Therefore, in the second part, we will analyse the therapeutic indications in different CKD stages. In any case, the individual assessment of factors which represent a higher or lower risk of fracture, the quantification of this risk (i.e. using tools such as FRAX(R)) and the potential indications for densitometry in patients with CKD could represent an important first step pending new clinical guidelines based on randomised studies which do not exclude CKD patients, all the while avoiding therapeutic nihilism in an area of growing importance


Assuntos
Humanos , Adulto , Pessoa de Meia-Idade , Idoso , Distúrbio Mineral e Ósseo na Doença Renal Crônica/diagnóstico , Distúrbio Mineral e Ósseo na Doença Renal Crônica/complicações , Fraturas por Osteoporose/etiologia , Osteoporose/diagnóstico , Densidade Óssea , Fatores de Risco
8.
BMC Nephrol ; 19(1): 240, 2018 09 20.
Artigo em Inglês | MEDLINE | ID: mdl-30236082

RESUMO

This report comments on the relevance and utility of the recently published (2017) KDIGO Clinical Practice Guideline Update for the diagnosis, evaluation, prevention and treatment of mineral bone disease in patients with chronic kidney disease (CKD-MBD) with respect to UK clinical practice. This document replaces all previously published Renal Association guidelines on the topic.


Assuntos
Distúrbio Mineral e Ósseo na Doença Renal Crônica/diagnóstico , Distúrbio Mineral e Ósseo na Doença Renal Crônica/terapia , Guias de Prática Clínica como Assunto/normas , Distúrbio Mineral e Ósseo na Doença Renal Crônica/epidemiologia , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto/normas , Reino Unido/epidemiologia
9.
Iran J Kidney Dis ; 12(4): 215-222, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-30087216

RESUMO

INTRODUCTION: Chronic kidney disease-mineral and bone disorder is a common complication in hemodialysis patients. The present study was designed to investigate the effects of flaxseed oil, a rich source of plant omega-3 fatty acid alpha-linolenic acid, on serum markers of bone formation and resorption in hemodialysis patients. MATERIALS AND METHODS: In this randomized controlled trial, 34 hemodialysis patients were randomly assigned to either the flaxseed oil or the control group. The patients in the flaxseed oil group received 6 g/d of flaxseed oil for 8 weeks, whereas the control group received 6 g/d of medium chain triglycerides oil. At baseline and the end of the 8th week, 7 mL of blood was obtained from each patient after a 12- to 14-hour fast and serum concentrations of osteocalcin, osteoprotegerin, N-telopeptide, and receptor activator of nuclear factor kappa B ligand were measured. RESULTS: Serum N-telopeptide concentration decreased significantly up to 17% in the flaxseed oil group at the end of week 8, as compared to baseline (P < .01), and the reduction was significant in comparison with the control group. There were no significant differences between the two groups in the mean changes of serum osteocalcin, osteoprotegerin, or receptor activator of nuclear factor kappa B ligand. CONCLUSIONS: This study indicates that daily consumption of 6 g/d of flaxseed oil may reduce bone resorption in hemodialysis patients.


Assuntos
Remodelação Óssea , Distúrbio Mineral e Ósseo na Doença Renal Crônica/dietoterapia , Suplementos Nutricionais , Óleo de Semente do Linho/administração & dosagem , Diálise Renal , Insuficiência Renal Crônica/terapia , Idoso , Biomarcadores/sangue , Reabsorção Óssea/sangue , Reabsorção Óssea/fisiopatologia , Reabsorção Óssea/prevenção & controle , Distúrbio Mineral e Ósseo na Doença Renal Crônica/sangue , Distúrbio Mineral e Ósseo na Doença Renal Crônica/diagnóstico , Distúrbio Mineral e Ósseo na Doença Renal Crônica/fisiopatologia , Colágeno Tipo I/sangue , Suplementos Nutricionais/efeitos adversos , Método Duplo-Cego , Feminino , Humanos , Irã (Geográfico) , Óleo de Semente do Linho/efeitos adversos , Masculino , Pessoa de Meia-Idade , Osteocalcina/sangue , Osteoprotegerina/sangue , Peptídeos/sangue , Ligante RANK/sangue , Insuficiência Renal Crônica/sangue , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
11.
Pediatr Nephrol ; 33(9): 1565-1575, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29872964

RESUMO

OBJECTIVE: Mineral and bone disorders associated to chronic kidney disease (CKD-MBD) are a daily challenge for pediatric nephrologists, with a significant risk of long-term bone and vascular comorbidities. METHODS: This single-center study is a prospective transversal evaluation of pediatric CKD patients of our center, part of the European 4C study. In addition to clinical and biochemical data, vascular and bone evaluation was performed: 24-h blood pressure assessment, carotid intima-media thickness (cIMT), pulse wave velocity (PWV), and high-resolution peripheral quantitative computed tomography (HR-pQCT) at the ultra-distal tibia. Results are presented as median (range). RESULTS: At a median age of 12.9 years (10.2-17.9), SDS height of - 1.0 (- 3.3-1.2) and estimated glomerular filtration rate (eGFR) of 33 mL/min/1.73m2 (11-72), 32 patients (8 girls) were evaluated. Median calcium, phosphate, parathyroid hormone (PTH), and 25 OHD3 levels were 2.44 mmol/L (2.24-2.78), 1.43 mmol/L (1.0-2.7), 80 pg/mL (9-359), and 70 nmol/L (32-116), respectively. Bivariate Spearman and backward multivariable analyses showed that calcium and bone trabecular thickness (Tb.Th), were positively associated with diastolic and mean arterial blood pressure (both for the 24 h, day and night assessment), whereas PTH and vitamin D did not predict blood pressure. CONCLUSIONS: We show that the greater the serum levels of calcium, the greater the (diastolic and mean) blood pressure; moreover, the greater the Tb. Th, the greater the (diastolic and mean) blood pressure. The role of calcium supplements to explain such findings in early pediatric CKD can be discussed.


Assuntos
Cálcio/sangue , Distúrbio Mineral e Ósseo na Doença Renal Crônica/fisiopatologia , Insuficiência Renal Crônica/fisiopatologia , Calcificação Vascular/fisiopatologia , Adolescente , Pressão Sanguínea/fisiologia , Densidade Óssea/fisiologia , Cálcio/fisiologia , Cálcio na Dieta/administração & dosagem , Cálcio na Dieta/efeitos adversos , Osso Esponjoso/diagnóstico por imagem , Osso Esponjoso/fisiopatologia , Espessura Intima-Media Carotídea , Criança , Distúrbio Mineral e Ósseo na Doença Renal Crônica/sangue , Distúrbio Mineral e Ósseo na Doença Renal Crônica/diagnóstico , Distúrbio Mineral e Ósseo na Doença Renal Crônica/etiologia , Feminino , Taxa de Filtração Glomerular , Humanos , Masculino , Estudos Prospectivos , Análise de Onda de Pulso , Diálise Renal/efeitos adversos , Insuficiência Renal Crônica/sangue , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/terapia , Tomografia Computadorizada por Raios X , Calcificação Vascular/sangue , Calcificação Vascular/diagnóstico , Calcificação Vascular/etiologia
12.
Ther Apher Dial ; 22(3): 220-228, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29781225

RESUMO

Measurement of circulating parathyroid hormone (PTH) levels is essential for optimal management of mineral and bone disorders (MBD) in chronic kidney disease (CKD) patients. There are two major types of PTH assays currently in use: intact parathyroid hormone (i-PTH) and whole PTH (w-PTH) assays. The i-PTH assay is the current standard, and considerable information regarding the management of CKD-MBD has been obtained with this method. However, several limitations have been found with the i-PTH assay. One limitation is that i-PTH assay also measures fragments other than full-length PTH (1-84). Another limitation is the existence of multiple readout methods of the i-PTH assay. The w-PTH assay is theoretically ideal because it exclusively detects full-length PTH (1-84). However, clinical data proving the advantages of w-PTH measurement are not sufficient. For uremic patients, Kidney Disease Improving Global Outcomes suggest that PTH levels should be maintained within approximately two to nine times the upper normal limit of the i-PTH assays. The most critical issue in the evaluation of PTH levels is the lack of definitive PTH assay method. Evidence-based recommendations on clinical management goals of PTH are warranted.


Assuntos
Distúrbio Mineral e Ósseo na Doença Renal Crônica/diagnóstico , Hormônio Paratireóideo/análise , Guias de Prática Clínica como Assunto , Distúrbio Mineral e Ósseo na Doença Renal Crônica/sangue , Distúrbio Mineral e Ósseo na Doença Renal Crônica/terapia , Humanos , Imunoensaio/métodos , Hormônio Paratireóideo/sangue
13.
Nefrologia ; 38(5): 476-490, 2018.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-29703451

RESUMO

Osteoporosis (OP) and chronic kidney disease (CKD) independently influence bone and cardiovascular health. A considerable number of patients with CKD, especially those with stages 3a to 5D, have a significantly reduced bone mineral density leading to a high risk of fracture and a significant increase in associated morbidity and mortality. Independently of classic OP related to age and/or gender, the mechanical properties of bone are also affected by inherent risk factors for CKD ("uraemic OP"). In the first part of this review, we will analyse the general concepts regarding bone mineral density, OP and fractures, which have been largely undervalued until now by nephrologists due to the lack of evidence and diagnostic difficulties in the context of CKD. It has now been proven that a reduced bone mineral density is highly predictive of fracture risk in CKD patients, although it does not allow a distinction to be made between the causes which generate it (hyperparathyroidism, adynamic bone disease and/or senile osteoporosis, etc.). Therefore, in the second part, we will analyse the therapeutic indications in different CKD stages. In any case, the individual assessment of factors which represent a higher or lower risk of fracture, the quantification of this risk (i.e. using tools such as FRAX®) and the potential indications for densitometry in patients with CKD could represent an important first step pending new clinical guidelines based on randomised studies which do not exclude CKD patients, all the while avoiding therapeutic nihilism in an area of growing importance.


Assuntos
Densidade Óssea , Distúrbio Mineral e Ósseo na Doença Renal Crônica/diagnóstico , Osteoporose/diagnóstico , Humanos , Osteoporose/etiologia , Fraturas por Osteoporose/epidemiologia , Fraturas por Osteoporose/etiologia , Insuficiência Renal Crônica/complicações , Fatores de Risco
14.
Nefrología (Madrid) ; 38(2): 207-212, mar.-abr. 2018. graf, tab
Artigo em Espanhol | IBECS | ID: ibc-171089

RESUMO

Introducción: El estudio del filtrado glomerular medido (FGm) o del estimado (FGe) es el eje de la evaluación adecuada de la función renal en la valoración de un potencial donante vivo renal. Nos planteamos estudiar la correlación entre las fórmulas de estimación del FG y los métodos de medición para determinar la función renal. Material y métodos: Analizamos la relación entre los valores basales de FGm con Tc-99m-DTPA (dietilenolene-triamino-pentaacetato) y aquellos estimados mediante las fórmulas Modification Diet Renal Disease de 4 variables (MDRD4) y Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) en una serie de donantes vivos de nuestra institución. Resultados: Incluimos a 64 donantes (70,6% mujeres; con una edad media de 48,3±11 años). La creatinina basal fue 0,8±0,1 y 1,1±0,2mg/dl un año posdonación. Las ecuaciones infraestiman el FG medido por Tc99m-DTPA (MDRD4 −9,4±25ml/min y p<0,05; CKD-EPI −4,4±21ml/min). La correlación entre las fórmulas estimativas y el método medido fue superior para CKD-EPI (r=0,41; p=0,004) que para MDRD4 (r=0,27; p=0,05). El FGe se redujo a 59,6±11 (MDRD4) y a 66,2±14ml/min (CKD-EPI) al año posdonación. Esto supone una reducción media del FGe de 28,2±16,7ml/min (MDRD4) y de 27,31±14,4ml/min (CKD-EPI) al año. Conclusión: En nuestra experiencia, CKD-EPI es la fórmula que mejor se correlaciona con el FGm-Tc99m-DTPA en la evaluación de la función renal para el cribado de donantes (AU)


Introduction: The evaluation of the measured Glomerular Filtration Rate (mGFR) or estimated Glomerular Filtration Rate (eGFR) is key in the proper assessment of the renal function of potential kidney donors. We aim to study the correlation between glomerular filtration rate estimation equations and the measured methods for determining renal function. Material and methods: We analysed the relationship between baseline GFR values measured by Tc-99m-DTPA (diethylene-triamine-pentaacetate) and those estimated by the four-variable Modification of Diet in Renal Disease (MDRD4) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations in a series of living donors at our institution. Results: We included 64 donors (70.6% females; mean age 48.3±11 years). Baseline creatinine was 0.8±0.1 mg/dl and it was 1.1±0.2 mg/dl one year after donation. The equations underestimated GFR when measured by Tc99m-DTPA (MDRD4-9.4 ± 25ml/min, P<.05, and CKD-EPI-4.4 ± 21ml/min). The correlation between estimation equations and the measured method was superior for CKD-EPI (r=.41; P<.004) than for MDRD4 (r=.27; P<.05). eGFR decreased to 59.6±11 (MDRD4) and 66.2±14ml/min (CKD-EPI) one year after donation. This means a mean eGFR reduction of 28.2±16.7 ml/min (MDRD4) and 27.31±14.4 ml/min (CKD-EPI) at one year. Conclusions: In our experience, CKD-EPI is the equation that better correlates with mGFR-Tc99m-DTPA when assessing renal function for donor screening purposes (AU)


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Taxa de Filtração Glomerular , Doadores Vivos , Distúrbio Mineral e Ósseo na Doença Renal Crônica/diagnóstico , Nefrectomia/métodos , Creatinina/análise , Pentetato de Tecnécio Tc 99m/administração & dosagem , Estudos Retrospectivos , Declaração de Helsinki , Análise Estatística
15.
Ann Intern Med ; 168(6): 422-430, 2018 03 20.
Artigo em Inglês | MEDLINE | ID: mdl-29459980

RESUMO

Description: The Kidney Disease: Improving Global Outcomes (KDIGO) 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) is a selective update of the prior CKD-MBD guideline published in 2009. The guideline update and the original publication are intended to assist practitioners caring for adults with CKD and those receiving long-term dialysis. Methods: Development of the guideline update followed an explicit process of evidence review and appraisal. The approach adopted by the Work Group and the evidence review team was based on systematic reviews of relevant trials, appraisal of the quality of the evidence, and rating of the strength of recommendations according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Searches of the English-language literature were conducted through September 2015 and were supplemented with targeted searches through February 2017. Final modification of the guidelines was informed by a public review process involving numerous stakeholders, including patients, subject matter experts, and industry and national organizations. Recommendations: The update process resulted in the revision of 15 recommendations. This synopsis focuses primarily on recommendations for diagnosis of and testing for CKD-MBD and treatment of CKD-MBD that emphasizes decreasing phosphate levels, maintaining calcium levels, and addressing elevated parathyroid hormone levels in adults with CKD stage G3a to G5 and those receiving dialysis. Key elements include basing treatment on trends in laboratory values rather than a single abnormal result and being cautious to avoid hypercalcemia when treating secondary hyperparathyroidism.


Assuntos
Distúrbio Mineral e Ósseo na Doença Renal Crônica/diagnóstico , Distúrbio Mineral e Ósseo na Doença Renal Crônica/terapia , Distúrbio Mineral e Ósseo na Doença Renal Crônica/prevenção & controle , Humanos , Hipercalcemia/prevenção & controle , Hiperfosfatemia/sangue , Hiperfosfatemia/prevenção & controle , Hormônio Paratireóideo/sangue , Diálise Renal
16.
Clin J Am Soc Nephrol ; 13(1): 36-44, 2018 01 06.
Artigo em Inglês | MEDLINE | ID: mdl-29208626

RESUMO

BACKGROUND AND OBJECTIVES: Niacin downregulates intestinal sodium-dependent phosphate transporter 2b expression and reduces intestinal phosphate transport. Short-term studies have suggested that niacin lowers serum phosphate concentrations in patients with CKD and ESRD. However, the long-term effects of niacin on serum phosphate and other mineral markers are unknown. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: The Atherothrombosis Intervention in Metabolic Syndrome with Low HDL/High Triglycerides: Impact on Global Health Trial was a randomized, double-blind, placebo-controlled trial testing extended release niacin in persons with prevalent cardiovascular disease. We examined the effect of randomized treatment with niacin (1500 or 2000 mg) or placebo on temporal changes in markers of mineral metabolism in 352 participants with eGFR<60 ml/min per 1.73 m2 over 3 years. Changes in each marker were compared over time between the niacin and placebo arms using linear mixed effects models. RESULTS: Randomization to niacin led to 0.08 mg/dl lower plasma phosphate concentrations per year of treatment compared with placebo (P<0.01) and 0.25 mg/dl lower mean phosphate 3 years after baseline (3.32 versus 3.57 mg/dl; P=0.03). In contrast, randomization to niacin was not associated with statistically significant changes in plasma intact fibroblast growth factor 23, parathyroid hormone, calcium, or vitamin D metabolites over 3 years. CONCLUSIONS: The use of niacin over 3 years lowered serum phosphorous concentrations but did not affect other markers of mineral metabolism in participants with CKD.


Assuntos
Distúrbio Mineral e Ósseo na Doença Renal Crônica/tratamento farmacológico , Intestinos/efeitos dos fármacos , Niacina/uso terapêutico , Fosfatos/sangue , Idoso , Biomarcadores/sangue , Cálcio/sangue , Canadá , Distúrbio Mineral e Ósseo na Doença Renal Crônica/sangue , Distúrbio Mineral e Ósseo na Doença Renal Crônica/diagnóstico , Distúrbio Mineral e Ósseo na Doença Renal Crônica/fisiopatologia , Preparações de Ação Retardada , Método Duplo-Cego , Feminino , Fatores de Crescimento de Fibroblastos/sangue , Taxa de Filtração Glomerular , Humanos , Absorção Intestinal/efeitos dos fármacos , Rim/fisiopatologia , Masculino , Pessoa de Meia-Idade , Niacina/efeitos adversos , Hormônio Paratireóideo/sangue , Proteínas Cotransportadoras de Sódio-Fosfato Tipo IIb/antagonistas & inibidores , Proteínas Cotransportadoras de Sódio-Fosfato Tipo IIb/metabolismo , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Vitamina D/sangue
17.
Nefrologia ; 38(1): 27-33, 2018.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-29137893

RESUMO

Bone disease related to chronic kidney disease and, particularly, to kidney transplant patients is a common cause or morbidity and mortality, especially due to a higher risk of osteoporotic fractures. Despite the fact that this has been known for decades, to date, an appropriate diagnostic strategy has yet to be established. Apart from bone biopsy, which is invasive and scarcely used, no other technique is available to accurately establish the risk of fracture in kidney patients. Techniques applied to the general population, such as bone densitometry, have not been subjected to sufficient external validation and their use is not systematic. This means that the identification of patients at risk of fracture and therefore those who are candidates for preventive strategies is an unmet need. Bone strength, defined as the ability of the bone to resist fracture, is determined by bone mineral density (measured by bone densitometry), trabecular architecture and bone tissue quality. The trabecular bone score estimates bone microarchitecture, and low values have been described as an independent predictor of increased fracture risk. Bone microindentation is a minimally invasive technique that measures resistance of the bone to micro-cracks (microscopic separation of mineralised collagen fibres), and therefore bone tissue biomechanical properties. The superiority over bone densitometry of the correlation between the parameters measured by trabecular bone score and microindentation with the risk of fracture in diverse populations led us to test its feasibility in chronic kidney disease and kidney transplant patients.


Assuntos
Distúrbio Mineral e Ósseo na Doença Renal Crônica/diagnóstico , Transplante de Rim , Absorciometria de Fóton , Densidade Óssea , Distúrbio Mineral e Ósseo na Doença Renal Crônica/etiologia , Estudos de Coortes , Fraturas Espontâneas/epidemiologia , Fraturas Espontâneas/etiologia , Fraturas Espontâneas/prevenção & controle , Fraturas de Estresse/diagnóstico por imagem , Fraturas de Estresse/etiologia , Fraturas de Estresse/prevenção & controle , Necessidades e Demandas de Serviços de Saúde , Humanos , Complicações Pós-Operatórias/diagnóstico , Risco , Transplantados
18.
Curr Vasc Pharmacol ; 16(2): 143-156, 2018 01 26.
Artigo em Inglês | MEDLINE | ID: mdl-28294047

RESUMO

BACKGROUND: Patients affected by Chronic Kidney Disease and Mineral Bone Disorder (CKD-MBD) have a high risk of cardiovascular (CV) mortality that is poorly explained by traditional risk factors. The newest medical treatments for CKD-MBD have been associated with encouraging, but still inconsistent, improvement in CV disease complications and patient survival. A better understanding of the biomarkers and mechanisms of left ventricular hypertrophy (LVH), atherosclerosis, and vascular calcification (VC) may help with diagnosis and treatment of the organ damage that occurs secondary to CKD-MBD, thus improving survival. Recent insights about fibroblast growth factor-23 (FGF23) and its co-receptor, Klotho, have led to marked advancement in interpreting data on vascular aging and CKDMBD. CONCLUSION: This review will discuss the current experimental and clinical evidence regarding FGF23 and Klotho, with a particular focus on their roles in LVH, atherosclerosis, and VC.


Assuntos
Aterosclerose/metabolismo , Distúrbio Mineral e Ósseo na Doença Renal Crônica/metabolismo , Fatores de Crescimento de Fibroblastos/metabolismo , Glucuronidase/metabolismo , Hipertrofia Ventricular Esquerda/metabolismo , Calcificação Vascular/metabolismo , Animais , Aterosclerose/diagnóstico , Aterosclerose/epidemiologia , Biomarcadores/metabolismo , Distúrbio Mineral e Ósseo na Doença Renal Crônica/diagnóstico , Distúrbio Mineral e Ósseo na Doença Renal Crônica/epidemiologia , Humanos , Hipertrofia Ventricular Esquerda/diagnóstico , Hipertrofia Ventricular Esquerda/epidemiologia , Prognóstico , Fatores de Risco , Transdução de Sinais , Calcificação Vascular/diagnóstico , Calcificação Vascular/epidemiologia
19.
Nephrology (Carlton) ; 23(3): 226-230, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-28052525

RESUMO

AIM: Calciprotein particles (CPPs), colloidal protein-mineral nanoparticles composed of solid-phase calcium phosphate and serum protein fetuin-A found in blood, are emerging as a novel component of chronic kidney disease-mineral and bone disorder (CKD-MBD). The relationship of CPPs with factors known to underlie the CKD-MBD pathophysiology is not well known.The aim of this study is to examine daily variations in CPPs as well as their association with mineral metabolism parameters in normal individuals and early-stage CKD patients. METHODS: Twenty subjects (10 healthy adults, 10 diabetic patients) were enrolled. Serum CPP Fetuin-A was measured and analyzed in relation to clinical parameters. RESULTS: Estimated glomerular filtration rates (eGFR) were 103 ± 11 and 75 ± 24 mL/min per 1.73 m2 in healthy adults and diabetic patients, respectively. Serum CPP Fetuin-A (g/L) were elevated at postprandial 2 h in diabetic patients. Furthermore, serum CPP Fetuin-A were inversely correlated with eGFR and serum 1,25-dihydroxyvitamin D3 and magnesium levels and were positively correlated with serum fibroblast growth factor-23. CONCLUSIONS: These findings indicated that serum CPP Fetuin-A were affected by food intake and may contribute to the pathophysiology of mineral metabolism in subjects with normal and moderately impaired renal function.


Assuntos
Fosfatos de Cálcio/sangue , Distúrbio Mineral e Ósseo na Doença Renal Crônica/sangue , Nefropatias Diabéticas/sangue , Insuficiência Renal Crônica/sangue , alfa-2-Glicoproteína-HS/análise , Adulto , Idoso , Biomarcadores/sangue , Calcitriol/sangue , Estudos de Casos e Controles , Distúrbio Mineral e Ósseo na Doença Renal Crônica/diagnóstico , Distúrbio Mineral e Ósseo na Doença Renal Crônica/fisiopatologia , Estudos Transversais , Nefropatias Diabéticas/diagnóstico , Nefropatias Diabéticas/fisiopatologia , Ingestão de Alimentos , Feminino , Fatores de Crescimento de Fibroblastos/sangue , Taxa de Filtração Glomerular , Humanos , Rim/fisiopatologia , Magnésio/sangue , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Ligação Proteica , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/fisiopatologia
20.
J Ren Nutr ; 27(6): 453-457, 2017 11.
Artigo em Inglês | MEDLINE | ID: mdl-29056164

RESUMO

The triad composed by α-Klotho, fibroblast growth factor-23, and its receptor are involved in the pathogenesis of chronic kidney disease-mineral and bone disorder. A disintegrin and metalloproteinase 17 (ADAM17) is a metalloproteinase causing the proteolytic shedding of α-Klotho from the cell membrane, and its role in chronic kidney disease-mineral and bone disorder is not yet known. We studied the circulating levels of the above-mentioned mediators in patients with secondary hyperparathyroidism due to uremia, compared to control subjects, as well as in patients with primary hyperparathyroidism. We also measured the immunofluorescence pattern of the relevant tissue proteins in specimens obtained from patients undergoing parathyroid surgery for secondary compared to primary hyperparathyroidism. Results showed that α-Klotho tissue levels are reduced, in the presence of increased ADAM17 tissue levels. In addition, we showed increased serum levels of the main product of ADAM17 proteolytic activity, tumor necrosis factor-α. Thus, we found a paradoxical situation, in secondary compared to primary hyperparathyroidism, that is, that in the face of increased tumor necrosis factor-α in circulation, both soluble and tissue α-Klotho are reduced significantly, despite increased tissue ADAM17. In conclusion, tissue and serum levels of α-Klotho seem to have become independent from the regulation induced by ADAM17, which constitutes therefore another tassel in the impaired α-Klotho-FGF23 receptor axis present in uremia.


Assuntos
Proteína ADAM17/sangue , Distúrbio Mineral e Ósseo na Doença Renal Crônica/diagnóstico , Distúrbio Mineral e Ósseo na Doença Renal Crônica/genética , Glucuronidase/sangue , Proteína ADAM17/genética , Proteína C-Reativa/metabolismo , Estudos de Casos e Controles , Distúrbio Mineral e Ósseo na Doença Renal Crônica/sangue , Fatores de Crescimento de Fibroblastos/sangue , Fatores de Crescimento de Fibroblastos/genética , Glucuronidase/genética , Humanos , Concentração de Íons de Hidrogênio , Hiperparatireoidismo Secundário/sangue , Hiperparatireoidismo Secundário/diagnóstico , Hiperparatireoidismo Secundário/genética , Hormônio Paratireóideo/sangue , Diálise Renal , Fator de Necrose Tumoral alfa/sangue , Fator de Necrose Tumoral alfa/genética , Uremia/sangue , Uremia/genética
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