Mark R. Hanudel

Effects of dietary iron intake and chronic kidney disease on fibroblast growth factor 23 metabolism in wild-type and hepcidin knockout mice

In the setting of normal kidney function, iron deficiency is associated with increased FGF23 production and cleavage, altering circulating FGF23 levels. Our objective was to determine how chronic kidney disease (CKD) and dietary iron intake affect FGF23 production and metabolism in wild-type (WT) and hepcidin knockout (HKO) mice. For 8 wk, the mice were fed diets that contained adenine (to induce CKD) or no adenine (control group), with either low-iron (4 ppm) or standard-iron (335 ppm) concentrations. The low-iron diet induced iron deficiency anemia in both the WT and HKO mice. Among the WT mice, in both the control and CKD groups, a low-iron compared with a standard-iron diet increased bone Fgf23 mRNA expression, C-terminal FGF23 (cFGF23) levels, and FGF23 cleavage as manifested by a lower percentage intact FGF23 (iFGF23). Independent of iron status, CKD was associated with inhibition of FGF23 cleavage. Similar results were observed in the HKO control and CKD groups. Dietary iron content was more influential on FGF23 parameters than the presence or absence of hepcidin. In the CKD mice (WT and HKO, total n = 42), independent of the effects of serum phosphate, iron deficiency was associated with increased FGF23 production but also greater cleavage, whereas worse kidney function was associated with increased FGF23 production but decreased cleavage. Therefore, in both the WT and HKO mouse models, dietary iron content and CKD affected FGF23 production and metabolism.

Erythropoietin stimulates murine and human fibroblast growth factor-23, revealing novel roles for bone and bone marrow.

Early stages of chronic kidney disease (CKD) are characterized by development of progressive anemia as well as concurrent marked elevation of the phosphaturic hormone fibroblast growth factor 23 (FGF23). As kidney function declines, FGF23 further increases and anemia worsens, due to either inadequate production of renal erythropoietin (EPO) or incidence of hypoferremia. Moreover, in CKD, anemia and elevated FGF23 levels are associated with left ventricular hypertrophy (LVH), CKD progression, and mortality. Treatment of CKD-related anemia involves iron repletion and erythropoietin (EPO) administration. EPO is one of the most extensively used medications in CKD, but its administration is associated with increased risks of cardiovascular disease and mortality. Although FGF23 levels increase early in CKD, the pathophysiological regulation of FGF23 is still not completely understood. Phosphate, 1,25-dihydroxyvitamin D (1,25D), parathyroid hormone, and calcium affect FGF23 production; however, these factors are still within normal ranges when bone and circulating FGF23 increase. Recent studies demonstrate intriguing associations between hypoxia, iron deficiency, and FGF23 upregulation. Indeed, in the settings of normal and impaired kidney function, iron deficiency potently increases bone Fgf23 expression. However, other anemia-related factors, including EPO, could potentially contribute to elevated FGF23 production. As both EPO therapy and FGF23 are associated with adverse outcomes in CKD, we explored the hypothesis that EPO is a previously unrecognized regulator of this phosphaturic hormone. Collectively, our pre-clinical findings suggest that modulating EPO exposure in CKD patients may lower FGF23 and thereby decrease its adverse effects. To examine whether exogenous EPO stimulates FGF23 in vivo, wild-type C57BL/6 mice at 6-8 weeks of age were injected with increasing doses of recombinant human EPO (25-250 U/g of body weight). A 3-day regimen induced a dose-dependent, 40-fold maximal increase in whole bone Fgf23 mRNA expression (Figure 1A), paralleled by increased serum total FGF23 as measured with an ELISA that detects both C-terminal FGF23 fragments (‘cFGF23’) and bioactive intact FGF23 (‘iFGF23’) (Figure

Increased serum hepcidin contributes to the anemia of chronic kidney disease in a murine model

Anemia is very common in chronic kidney disease (CKD) patients,[1][1] and has been associated with adverse cardiovascular outcomes in this population.[2][2] The pathogenesis of CKD-associated anemia is multifactorial, contributed to by relative erythropoietin (Epo) deficiency, absolute and

Treatment of Pediatric Chronic Kidney Disease-Mineral and Bone Disorder

Purpose of ReviewIn this paper, we review the pathogenesis and treatment of chronic kidney disease-mineral and bone disorder (CKD-MBD), especially as it relates to pediatric CKD patients.Recent FindingsDisordered regulation of bone and mineral metabolism in CKD may result in fractures, skeletal deformities, and poor growth, which is especially relevant for pediatric CKD patients. Moreover, CKD-MBD may result in extra-skeletal calcification and cardiovascular morbidity. Early increases in fibroblast growth factor 23 (FGF23) levels play a key, primary role in CKD-MBD pathogenesis. Therapeutic approaches in pediatric CKD-MBD aim to minimize complications to the growing skeleton and prevent extra-skeletal calcifications, mainly by addressing hyperphosphatemia and secondary hyperparathyroidism. Ongoing clinical trials are focused on assessing the benefit of FGF23 reduction in CKD.SummaryCKD-MBD is a systemic disorder that has significant clinical implications. Treatment of CKD-MBD in children requires special consideration in order to maximize growth, optimize skeletal health, and prevent cardiovascular disease.

Effects of erythropoietin on fibroblast growth factor 23 in mice and humans

Background Erythropoietin (EPO) has been reported as a novel determinant of fibroblast growth factor 23 (FGF23) production; however, it is unknown whether FGF23 is stimulated by chronic exposure to EPO or by EPO administration in nonpolycystic chronic kidney disease (CKD) models. Methods We analyzed the effects of chronic EPO on FGF23 in murine models with chronically high EPO levels and normal kidney function. We studied the effects of exogenous EPO on FGF23 in wild-type mice, with and without CKD, injected with EPO. Also, in four independent human CKD cohorts, we evaluated associations between FGF23 and serum EPO levels or exogenous EPO dose. Results Mice with high endogenous EPO have elevated circulating total FGF23, increased disproportionately to intact FGF23, suggesting coupling of increased FGF23 production with increased proteolytic cleavage. Similarly, in wild-type mice with and without CKD, a single exogenous EPO dose acutely increases circulating total FGF23 out of proportion to intact FGF23. In these murine models, the bone marrow is shown to be a novel source of EPO-stimulated FGF23 production. In humans, serum EPO levels and recombinant human EPO dose are positively and independently associated with total FGF23 levels across the spectrum of CKD and after kidney transplantation. In our largest cohort of 680 renal transplant recipients, serum EPO levels are associated with total FGF23, but not intact FGF23, consistent with the effects of EPO on FGF23 production and metabolism observed in our murine models. Conclusion EPO affects FGF23 production and metabolism, which may have important implications for CKD patients.

Levels of the erythropoietin-responsive hormone erythroferrone in mice and humans with chronic kidney disease

Erythroferrone (ERFE) is a hormone produced by human and murine erythroid precursors that acts directly on the liver to decrease hepcidin production.[1][1] Hepcidin regulates circulating iron concentrations by binding to the cellular iron exporter ferroportin, causing its internalization and

Fractures and Osteomalacia in a Patient Treated With Frequent Home Hemodialysis

Bone deformities and fractures are common consequences of renal osteodystrophy in the dialysis population. Persistent hypophosphatemia may be observed with more frequent home hemodialysis regimens, but the specific effects on the skeleton are unknown. We present a patient with end-stage renal disease treated with frequent home hemodialysis who developed severe bone pain and multiple fractures, including a hip fracture and a tibia-fibula fracture complicated by nonunion, rendering her nonambulatory and wheelchair bound for more than a year. A bone biopsy revealed severe osteomalacia, likely secondary to chronic hypophosphatemia and hypocalcemia. Treatment changes included the addition of phosphate to the dialysate, a higher dialysate calcium concentration, and increased calcitriol dose. Several months later, the patient no longer required a wheelchair and was able to ambulate without pain. Repeat bone biopsy revealed marked improvements in bone mineralization and turnover parameters. Also, with increased dialysate phosphate and calcium concentrations, as well as increased calcitriol, circulating fibroblast growth factor 23 levels increased.

Fibroblast growth factor 23: fueling the fire

In chronic kidney disease, systemic inflammation is common and associated with mortality. The present study demonstrates that fibroblast growth factor 23 (FGF23) contributes to uremic inflammation by increasing hepatic expression and secretion of inflammatory cytokines. FGF23 binds to hepatic FGFR4, inducing calcineurin/nuclear factor of activated T-cell signaling, resulting in increased expression of interleukin 6 and C-reactive protein. The proinflammatory effects of FGF23 are inhibited by an isoform-specific FGFR4 blocking antibody and by cyclosporine, a calcineurin inhibitor.

The accuracy of a continuous volumetric balancing system in pediatric continuous renal replacement therapy

Background In pediatric continuous renal replacement therapy (CRRT) patients, accurate ultrafiltration (UF) measurement is essential, as both over- and under-UF may result in suboptimal outcomes. Traditionally, CRRT has relied on scale-based UF measurements; however, the recent development of a continuous volumetric balancing system has allowed for the advent of scale-less CRRT. Methods To assess the accuracy of the volumetric balancing system, we designed a continuously measuring digital scale, which accounted for dialysate use and collected effluent, allowing us to independently measure UF volume and compare it with the machine reported UF volume. Results In four low weight (6.9-16.7 kg) pediatric CRRT patients, we measured the UF volume over 20 separate runs, comprising a total of 318 hours. Over this time, the total measured UF volume was 50,550 mL ± 296 mL, whereas the total reported UF volume was 50,733 mL, a difference of 183 mL ± 296 mL (0.6 ± 0.9 ml/h), or 0.4 ± 0.6%. For each patient, over 48-112 hours per patient, the differences between the total measured and total reported UF volumes ranged from -7.8 ± 1.7 ml/h to +9.7 ± 1.8 ml/h, or -6.0 ± 1.3% to +5.4 ± 1.0%. Conclusions In low-weight, pediatric CRRT patients, the scale-less continuous volumetric balancing system delivers accurate ultrafiltration.

Non-renal-Related Mechanisms of FGF23 Pathophysiology

Purpose of ReviewWe will review non-renal-related mechanisms of fibroblast growth factor 23 (FGF23) pathophysiology.Recent FindingsFGF23 production and metabolism may be affected by many bone, mineral, and kidney factors. However, it has recently been demonstrated that other factors, such as iron status, erythropoietin, and inflammation, also affect FGF23 production and metabolism. As these non-mineral factors are especially relevant in the setting of chronic kidney disease (CKD), they may represent emerging determinants of CKD-associated elevated FGF23 levels. Moreover, FGF23 itself may promote anemia and inflammation, thus contributing to the multifactorial etiologies of these CKD-associated comorbidities.SummaryCKD-relevant, non-mineral-related, bidirectional relationships exist between FGF23 and anemia, and between FGF23 and inflammation. Iron deficiency, anemia, and inflammation affect FGF23 production and metabolism, and FGF23 itself may contribute to anemia and inflammation, highlighting complex interactions that may affect aspects of CKD pathogenesis and treatment.