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Resumen Antecedentes y objetivo En este estudio presentamos los resultados del subgrupo de pacientes espanoles del estudio VERIFIE, primer estudio postautorizacion prospectivo que evalua la seguridad y efectividad a largo plazo del oxihidroxido sucroferrico (OHS) en pacientes en dialisis con hiperfosfatemia durante la practica clinica habitual. Pacientes y metodos Se incluyeron pacientes en hemodialisis y dialisis peritoneal con indicacion de tratamiento con OHS. La duracion del seguimiento fue de 12 a 36 meses desde el inicio del tratamiento con OHS. Las variables primarias de seguridad fueron la incidencia de reacciones adversas a medicamentos, eventos medicos de interes especial y variaciones en los parametros del hierro. La efectividad del OHS se evaluo mediante el cambio en los niveles de fosforo serico. Resultados Se reclutaron 286 pacientes y se analizaron los datos de 282. De estos 282 pacientes, 161 (57,1%) abandonaron el estudio de manera prematura y un 52,5% recibieron tratamiento concomitante con otros captores de fosforo. Un 35,1% reportaron reacciones adversas a medicamentos y la mayoria fueron de tipo gastrointestinal (77,1%) y de intensidad leve/moderada (83,7%). Un 14,2% de los pacientes presentaron eventos medicos de interes especial, de los que el 93,7% fueron leves/moderados. Se observo un incremento de la ferritina (386,66 vs. 447,55 ng/mL; p = 0,0013) y saturacion de la transferrina (28,07 vs. 30,34%; p = 0,043) desde el inicio hasta la ultima visita. Los niveles de fosforo serico disminuyeron progresivamente desde 5,69 mg/dL al inicio hasta 4,84 mg/dL en la ultima visita (p Conclusiones El OHS presento un perfil de efectividad favorable, un perfil de seguridad similar al observado en el estudio internacional con una mayoria de efectos adversos de severidad leve/moderada, y un numero reducido de comprimidos diarios en pacientes espanoles en dialisis.

Phosphorus is a vital element for life found in most foods as a natural component, but it is also one of the most used preservatives added during food processing. High serum phosphorus contributes to develop vascular calcification in chronic kidney disease; however, it is not clear its effect in a population without kidney damage. The objective of this in vivo and in vitro study was to investigate the effect of high phosphorus exposure on the aortic and serum levels of miR-145 and its effect on vascular smooth muscle cell (VSMCs) changes towards less contractile phenotypes. The study was performed in aortas and serum from rats fed standard and high-phosphorus diets, and in VSMCs exposed to different concentrations of phosphorus. In addition, miR-145 silencing and overexpression experiments were carried out. In vivo results showed that in rats with normal renal function fed a high P diet, a significant increase in serum phosphorus was observed which was associated to a significant decrease in the aortic α-actin expression which paralleled the decrease in aortic and serum miR-145 levels, with no changes in the osteogenic markers. In vitro results using VSMCs corroborated the in vivo findings. High phosphorus first reduced miR-145, and afterwards α-actin expression. The miR-145 overexpression significantly increased α-actin expression and partially prevented the increase in calcium content. These results suggest that miR-145 could be an early biomarker of vascular calcification, which could give information about the initiation of the transdifferentiation process in VSMCs.

Introduction MicroRNAs (miRs) regulate vascular calcification (VC), and their quantification may contribute to suspicion of the presence of VC. Methods The study was performed in four phases. Phase 1: miRs sequencing of rat calcified and non-calcified aortas. Phase 2: miRs with the highest rate of change, plus miR-145 [the most abundant miR in vascular smooth muscle cells (VSMCs)], were validated in aortas and serum from rats with and without VC. Phase 3: the selected miRs were analyzed in epigastric arteries from kidney donors and recipients, and serum samples from general population. Phase 4: VSMCs were exposed to different phosphorus concentrations, and miR-145 and miR-486 were overexpressed to investigate their role in VC. Results miR-145, miR-122-5p, miR-486 and miR-598-3p decreased in the rat calcified aortas, but only miR-145 and miR-486 were detected in serum. In human epigastric arteries, miR-145 and miR-486 were lower in kidney transplant recipients compared with donors. Both miRs inversely correlated with arterial calcium content and with VC (Kauppila index). In the general population, the severe VC was associated with the lowest serum levels of both miRs. The receiver operating characteristic curve showed that serum miR-145 was a good biomarker of VC. In VSMCs exposed to high phosphorus, calcium content, osteogenic markers (Runx2 and Osterix) increased, and the contractile marker (α-actin), miR-145 and miR-486 decreased. Overexpression of miR-145, and to a lesser extent miR-486, prevented the increase in calcium content induced by high phosphorus, the osteogenic differentiation and the loss of the contractile phenotype. Conclusion miR-145 and miR-486 regulate the osteogenic differentiation of VSMCs, and their quantification in serum could serve as a marker of VC.

Resumen: Antecedentes y objetivo: Mantener niveles adecuados de fósforo sérico en el paciente con enfermedad renal crónica es fundamental para su correcto manejo clínico. Sin embargo resulta difícil su control de forma aislada porque normalmente se asocian con aumentos séricos de hormona paratiroidea (PTH). En el presente estudio se analizaron los efectos de la hiperfosfatemia aislada, en presencia de PTH elevada y normal, sobre la inflamación, hipertrofia y fibrosis cardíaca en un modelo de insuficiencia renal experimental. Materiales y métodos: Se formaron cuatro grupos de ratas. A dos grupos se les realizó paratiroidectomía total (PTx). A las ratas con Ca

The authors wish to thank Instituto de Salud Carlos III (ISCIII; PI16/00637 and PI19/00532), the ISCIII Retic REDinREN (RD06/0016/1013, RD12/0021/0023, RD16/0009/0017 and RD16/0009/0021), Fondo Europeo de Desarrollo Regional (FEDER), Plan Estatal de I+D+I 2013-2016, Plan de Ciencia, Tecnología e Innovación 2013-2017 y 2018-2022 del Principado de Asturias (GRUPIN14-028, IDI-2018-000152), Fundación Renal Iñigo Álvarez de Toledo (FRIAT), and University of Oviedo. B.M.C. was supporting by a graduate fellowship from the Gobierno del Principado de Asturias (“Severo Ochoa” program), J.M.V. by a graduate fellowship from the Ministerio de Ciencia, Innovación y Universidades (FPU program), J.R.C. by postdoctoral contracts from the “Juan de la Cierva” (IJCI-2017-32070, Ministerio de Ciencia e Innovación, Spain) and “Sara Borrell” programs (CD19/00120, from ISCIII), C.A.M. by REDinREN-FINBA (RD16/0009/0017) and N.C.L. has been supported by FINBA-GRUPIN14-028 and IDI-2018-000152.

Background and Aims Bone fragility fractures (bone fractures) are extremely frequent in haemodialysis (HD) patients. Serum phosphate (P) has been suggested as a risk factor for bone fracture, nonetheless, evidence is poor. The aim of this study was to assess the association between incidence of bone fractures and serum phosphate (P), calcium (Ca) and parathyroid hormone (PTH) in patients from the COSMOS study. Method COSMOS is an observational, prospective, open cohort study with 3 years of follow-up including 6797 haemodialysis patients from 227 centres randomly selected from 20 European countries. At baseline, demographics, comorbidities, treatments, serum biochemical parameters of the previous six months and bone fractures of the previous 12 months were collected. Every 6 months, all these variables, outcomes, and incident bone fractures, were collected. Patients who had at least one bone fracture during follow-up were compared with those who had not. Multivariate binary logistic regression and Poisson regression were used to assess the association between incidence of bone fractures and serum P, Ca and PTH. Time to fracture (and possible re-fracture) was also evaluated using Cox regression and Cox regression for recurrent events. All the results were adjusted by 23 variables including Ca, P, PTH, albumin and haemoglobin (full adjusted model). Results Analysis included 6274 patients who had follow-up data and non-missing information regarding bone fractures at baseline and during follow-up; 252 patients (4.0%), suffered at least one incident bone fracture. The fractured patients were older (68.1±12.9 vs. 63.8±14.5 years, p Multivariate binary logistic regression showed that “well known risk factors for bone fracture”, such as a previous bone fracture (OR: 7.78[95%CI:4.83-12.55], p 800 pg/mL (OR: 1.60[95%CI: 1.01-2.55], p=0.047), were associated with a higher incidence of follow-up bone fractures. In addition to the “well known bone risk factors for fracture”, serum P > 6.1 mg/dL (OR: 1.50[95% CI: 1.07-2.11], p=0.02) and serum Ca > 9.7 mg/dL (OR: 1.42[95%CI: 1.01-2.03], p=0.043), were also associated with a higher incidence of bone fractures in the full-adjusted model. These findings were partly consistent with Poisson regression for serum P >6.1 mg/dL (IRR: 1.46[95% CI: 1.00-2.13], p=0.0085) and serum Ca > 9.7 mg/dL (IRR: 1.49[95%CI: 1.06-2.08], p=0.0047), but not for PTH. In addition, Cox regression analysis showed association between bone fractures and serum P >6.1 mg/dl (HR: 1.61 [95%CI: 1.16-2.24], p=0.0049) and 1.60 [95%CI: 1.14-2.24] (p=0.0066) for simple and recurrent events respectively, but no association was found with serum Ca and PTH in the 2 full-adjusted models for the Cox regression analyses. Conclusion In COSMOS, a large haemodialysis patient’s cohort with 3 years follow up, serum P was the only biochemical parameter that remained as a significant risk factor for bone fractures after 4 statistic approaches. Thus, for the first time, in a large scale well controlled study, high serum P has been identified as a new independent potential risk factor for incident bone fractures in haemodialysis patients.

Resumen: La osteoporosis (OP) y la enfermedad renal crónica (ERC) influyen independientemente en la salud ósea. Numerosos pacientes con ERC presentan una disminución de densidad mineral ósea (DMO), un elevado riesgo de fracturas por fragilidad ósea y un incremento de su morbimortalidad. Con el envejecimiento de la población estos hechos no son dependientes solo de la «osteodistrofia renal» sino también de la OP asociada. Dado que la DMO tiene capacidad predictiva en pacientes con ERC (parte I), ahora analizaremos las implicaciones terapéuticas derivadas. Análisis post hoc de estudios aleatorizados han mostrado que fármacos como alendronato, risedronato, raloxifeno, teriparatida o denosumab tienen una eficacia comparable a la población general en pacientes con una disminución leve-moderada del filtrado glomerular (especialmente ERC-3). Estos estudios tienen limitaciones, pues incluyen mayoritariamente mujeres «sanas», sin diagnóstico conocido de ERC y habitualmente con parámetros normales de laboratorio; sin embargo, también existen datos positivos preliminares en estadios más avanzados (ERC-4) y más limitados en ERC-5D. Por todo ello, al menos en ausencia de alteraciones significativas del metabolismo mineral (i.e., hiperparatiroidismo severo), el beneficio potencial de dichos fármacos debería ser considerado en pacientes que presenten un riesgo de fractura elevado o muy elevado. Es novedad importante que las nuevas guías no condicionan su uso a la práctica de una biopsia ósea previa y que el beneficio/riesgo de estos fármacos podría estar justificado. Sin embargo, debemos considerar que la mayoría de estudios no son consistentes y tienen un bajo grado de evidencia, por lo que la indicación farmacológica (riesgo/beneficio) debe ser individualizada y prudente. Abstract: Osteoporosis (OP) and chronic kidney disease (CKD) both independently affect bone health. A significant number of patients with CKD have decreased bone mineral density (BMD), are at high risk of fragility fractures and have an increased morbidity and mortality risk. With an ageing population, these observations are not only dependent on “renal osteodystrophy” but also on the associated OP. As BMD predicts incident fractures in CKD patients (part I), we now aim to analyse the potential therapeutic consequences. Post-hoc analyses of randomised studies have shown that the efficacy of drugs such as alendronate, risedronate, raloxifene, teriparatide and denosumab is similar to that of the general population in patients with a mild/moderate decline in their glomerular filtration rate (especially CKD-3). These studies have some flaws however, as they included mostly “healthy” women with no known diagnosis of CKD and generally with normal lab test results. Nevertheless, there are also some positive preliminary data in more advanced stages (CKD-4), even though in CKD-5D they are more limited. Therefore, at least in the absence of significant mineral metabolism disorders (i.e. severe hyperparathyroidism), the potential benefit of these drugs should be considered in patients with a high or very high fracture risk. It is an important change that the new guidelines do not make it a requirement to first perform a bone biopsy and that the risk/benefit ratio of these drugs may be justified. However, we must also be aware that most studies are not consistent and the level of evidence is low. Consequently, any pharmacological intervention (risk/benefit) should be prudent and individualised. Palabras clave: Osteoporosis, CKD-MBD, Densidad mineral ósea, Fracturas, ERC, DEXA, Bisfosfonatos, Denosumab, Romosozumab, Keywords: Osteoporosis, CKD-MBD, Bone mineral density, Fractures, CKD, DEXA, Bisphosphonates, Denosumab, Romosozumab

The impressive estimated number of chronic kidney disease (CKD) patients in the world justifies any possible effort at implementing preventive measures of disease progression. Renal insufficiency is associated with significant changes in the electrolyte handling and body balance of sodium, potassium, phosphate, magnesium, and calcium, all of which are biologically vital molecules. Dietary habits could contribute significantly to the optimal management of possible derangements. In this review, we examined the available evidence recommending dietary prescriptions for these five elements aiming at reducing CKD progression. Clear evidence that specific dietary prescriptions may halt or reduce CKD progression is lacking. However, some practical recommendations are possible to prescribe the best possible therapy to the individual CKD patient.

Background: Treatment advances have reduced the adverse events associated with hematopoietic stem cell transplant (HSCT) and led to an increased number of transplants performed. HSCT patients are living longer with concerns on long-term outcomes. Bone fragility and fracture are at the forefront for long-term morbidities post-HSCT. Results: In HSCT recipients, evidence has accumulated to support recommendations for more extensive monitoring of bone fragility and more appropriate administration of osteoporosis pharmacotherapies for patients at high risk of bone loss and/or fracture. Conclusion: This executive summary reports and summarizes the main recommendations published previously, including bone assessment, dietary and lifestyle recommendations and osteoporosis medication., SCOPUS: re.j, info:eu-repo/semantics/published

Fibrosis is a process characterized by an excessive accumulation of the extracellular matrix as a response to different types of tissue injuries, which leads to organ dysfunction. The process can be initiated by multiple and different stimuli and pathogenic factors which trigger the cascade of reparation converging in molecular signals responsible of initiating and driving fibrosis. Though fibrosis can play a defensive role, in several circumstances at a certain stage, it can progressively become an uncontrolled irreversible and self-maintained process, named pathological fibrosis. Several systems, molecules and responses involved in the pathogenesis of the pathological fibrosis of chronic kidney disease (CKD) will be discussed in this review, putting special attention on inflammation, renin-angiotensin system (RAS), parathyroid hormone (PTH), fibroblast growth factor 23 (FGF23), Klotho, microRNAs (miRs), and the vitamin D hormonal system. All of them are key factors of the core and regulatory pathways which drive fibrosis, having a great negative kidney and cardiac impact in CKD.

Background In chronic kidney disease, the activation of the renin–angiotensin–aldosterone system (RAAS) and renal inflammation stimulates renal fibrosis and the progression to end-stage renal disease. The low levels of vitamin D receptor (VDR) and its activators (VDRAs) contribute to worsen secondary hyperparathyroidism and renal fibrosis. Methods The 7/8 nephrectomy model of experimental chronic renal failure (CRF) was used to examine the anti-fibrotic effects of treatment with two VDRAs, paricalcitol and calcitriol, at equivalent doses (3/1 dose ratio) during 4 weeks. Results CRF increased the activation of the RAAS, renal inflammation and interstitial fibrosis. Paricalcitol treatment reduced renal collagen I and renal interstitial fibrosis by decreasing the activation of the RAAS through renal changes in renin, angiotensin receptor 1 (ATR1) and ATR2 mRNAs levels and renal inflammation by decreasing renal inflammatory leucocytes (CD45), a desintegrin and metaloproteinase mRNA, transforming growth factor beta mRNA and protein, and maintaining E-cadherin mRNA levels. Calcitriol showed similar trends without significant changes in most of these biomarkers. Conclusions Paricalcitol effectively attenuated the renal interstitial fibrosis induced by CRF through a combination of inhibitory actions on the RAAS, inflammation and epithelial/mesenchymal transition.

Background The iron-based phosphate binder (PB), sucroferric oxyhydroxide (SFOH), is indicated to control serum phosphorus levels in patients with chronic kidney disease on dialysis. Methods This non-interventional, prospective, multicentre, cohort study conducted in seven European countries evaluated the safety and effectiveness of SFOH in dialysis patients with hyperphosphataemia in routine practice. Safety outcomes included adverse drug reactions (ADRs) and changes in iron-related parameters. SFOH effectiveness was evaluated by changes-from-baseline (BL) in serum phosphorus and percentage of patients achieving in-target phosphorus levels. Results The safety analysis set included 1365 patients (mean observation: 420.3 ± 239.3 days). Overall, 682 (50.0%) patients discontinued the study. Mean SFOH dose during the observation period was 1172.7 ± 539.9 mg (2.3 pills/day). Overall, 617 (45.2%) patients received concomitant PB(s) during SFOH treatment. ADRs and serious ADRs were observed for 531 (38.9%) and 26 (1.9%) patients. Most frequent ADRs were diarrhoea (194 patients, 14.2%) and discoloured faeces (128 patients, 9.4%). Diarrhoea generally occurred early during SFOH treatment and was mostly mild and transient. Small increases from BL in serum ferritin were observed (ranging from +12 to +75 µg/L). SFOH treatment was associated with serum phosphorus reductions (6.3 ± 1.6 mg/dL at BL versus 5.3 ± 1.8 mg/dL at Month 30; ΔBL: −1.0 mg/dL, P Conclusions SFOH has a favourable safety and tolerability profile in a real-world setting, consistent with results of the Phase 3 study. Moreover, SFOH improved serum phosphorus control with a low daily pill burden.

Background and Aims The stratification of early cardiovascular (CV) risk is a major unmet need in chronic kidney disease (CKD). Since angiogenic T-cells are emerging mediators of vascular homeostasis and have been linked to CV disease (CVD), this study evaluated the frequency of circulating angiogenic T-cells in CKD patients undergoing peritoneal dialysis (CKD-5D) and their potential as predictive biomarkers of CVD. Method In 30 peritoneal dialysis patients and 16 matched healthy controls (HC), we quantified: Vascular calcification (by Kauppila Index); left carotid intima media thickness (lc-IMT by ultrasound), carotid adventitial vasa vasorum density (an early marker of atherosclerosis stage, by Superb Microvascular Ultrasound Image), pulse wave velocity (a marker of vascular stiffness and dysfunction, using the Complior Analyzer), angiogenic T cell frequency in blood (by Flow cytometry) and the traditional 10-year CVD risk (using the SCORE chart). Results As expected, CKD-5D patients exhibited higher Kauppila index (p0.05) and did not correlate with Kauppila (r=-0.350, p=0.080) or lcIMT (r=-0.154, p=0.600), but strongly associated negatively with both pulse wave velocity (r=-0.734, p Conclusion Angiogenic-T cell frequency was decreased in CKD-5D patients and could be considered as biomarkers of vascular dysfunction and early atherosclerosis stage.

Background and Aims Diabetes is the most common cause of chronic kidney disease (CKD) stage 5 and a relevant risk factor for mortality. The available CKD-MBD guidelines do not make differences between diabetics and non-diabetics regarding the optimal targets of the serum bone and mineral biochemical parameters. Thus, the objective of this analysis of COSMOS was to compare the association between the main serum bone and mineral biochemical parameters (calcium-Ca, phosphorus-P and parathyroid hormone-PTH) and mortality in diabetic and non-diabetic patients in haemodialysis. Method COSMOS is a 3-year, observational, prospective, open-cohort study that includes 6797 patients from 227 dialysis centres that were randomly selected from 20 European countries. Cox proportional hazard regression models with penalized splines smoothing were used to analyse the association between relative risk of mortality vs. Ca, P or PTH. Hazard ratios were adjusted by demographics, comorbidities, treatments and biochemical parameters. Interaction analysis was used to analyse if diabetes can influence the association between relative risk of mortality and Ca, P and PTH. Results The present analysis includes 6306 patients with follow-up data and accurate information on diabetes status. The mortality rate in COSMOS was 13.3 deaths per 100 patient-years (17.8 in diabetics and 11.4 in non-diabetics). At baseline, diabetic patients were older (66.7 ± 11.7 vs. 62.8 ± 15.3 years, p Conclusion These results suggest for the first time a differential effect of diabetes on the association between relative risk of mortality and serum PTH. High serum PTH predicts death only in diabetics. These findings could have relevant implications for the diagnosis and treatment of CKD-MBD in diabetic and non-diabetic patients in haemodialysis.

BackgroundIn chronic kidney disease, serum phosphorus (P) elevations stimulate parathyroid hormone (PTH) production, causing severe alterations in the bone–vasculature axis. PTH is the main regulator of the receptor activator of nuclear factor κB (RANK)/RANK ligand (RANKL)/osteoprotegerin (OPG) system, which is essential for bone maintenance and also plays an important role in vascular smooth muscle cell (VSMC) calcification. The discovery of a new RANKL receptor, leucine-rich repeat-containing G-protein-coupled receptor 4 (LGR4), which is important for osteoblast differentiation but with an unknown role in vascular calcification (VC), led us to examine the contribution of LGR4 in high P/high PTH–driven VC.MethodsIn vivo studies were conducted in subtotally nephrectomized rats fed a normal or high P diet, with and without parathyroidectomy (PTX). PTX rats were supplemented with PTH(1–34) to achieve physiological serum PTH levels. In vitro studies were performed in rat aortic VSMCs cultured in control medium, calcifying medium (CM) or CM plus 10−7 versus 10−9 M PTH.ResultsRats fed a high P diet had a significantly increased aortic calcium (Ca) content. Similarly, Ca deposition was higher in VSMCs exposed to CM. Both conditions were associated with increased RANKL and LGR4 and decreased OPG aorta expression and were exacerbated by high PTH. Silencing of LGR4 or parathyroid hormone receptor 1 (PTH1R) attenuated the high PTH–driven increases in Ca deposition. Furthermore, PTH1R silencing and pharmacological inhibition of protein kinase A (PKA), but not protein kinase C, prevented the increases in RANKL and LGR4 and decreased OPG. Treatment with PKA agonist corroborated that LGR4 regulation is a PTH/PKA-driven process.ConclusionsHigh PTH increases LGR4 and RANKL and decreases OPG expression in the aorta, thereby favouring VC. The hormone’s direct pro-calcifying actions involve PTH1R binding and PKA activation.

Resumen Objetivos Valorar si la fuerza de agarre y la dificultad para realizar actividades cotidianas podrían ser predictores de caídas y fracturas osteoporóticas. Material y métodos Se seleccionaron aleatoriamente 624 hombres y mujeres mayores de 50 años, que fueron seguidos durante 8 años para conocer la incidencia de caídas y fracturas osteoporóticas no vertebrales. Al inicio se midió la fuerza de agarre en manos y se cumplimentó un cuestionario con variables clínicas, factores de riesgo relacionados con la osteoporosis y cuestiones relativas a la dificultad o incapacidad para realizar actividades cotidianas. Resultados La fuerza de agarre en manos no se asoció con la incidencia de caídas y fracturas. Sin embargo, la imposibilidad o dificultad de “estar sentado más de 1 hora en silla dura”, “quitarse los calcetines o las medias” e “inclinarse desde una silla para coger un objeto del suelo” se asoció con caídas: 1,83 (1,16-2,89); 1,85 (1,14-3,00) y 1,68 (1,04-2,70), respectivamente. Del mismo modo, la imposibilidad o dificultad de “llevar durante 10 metros un objeto de 10 kilos” y “levantar una caja con 6 botellas y ponerlas sobre una mesa” se asoció con fractura: 2,82 (1,21-6,59) y 2,54 (1,12-5,81) respectivamente. Conclusiones No se encontró asociación entre la fuerza de agarre e incidencia de caídas y fracturas osteporóticas, pero sí con dificultad o incapacidad para realizar actividades cotidianas. Las relacionadas con mayor fuerza se asociaron con fractura, mientras que las relacionadas con capacidad funcional se asociaron con caídas. Realizar cuestionarios sencillos podría ayudar a predecir eventos antes de que ocurran.

Nephrology is a young medical specialty that has evolved and expanded during the last 4 decades of the past century, becoming recognized as one of the most innovative and challenging medical specialties. The training of nephrology takes place mainly in public hospitals, and there are important variations in the duration and assessment of training among the European countries. The Union of European Medical Specialties (UEMS) Renal Section and the European Renal Association-European Dialysis and Transplant Association have been working jointly since 2010 to harmonize European nephrology training and more recently to establish the European Certificate in Nephrology (ECN). The first two editions of the ECN were held in early 2017 and 2018. In total, 122 candidates from 26 countries have sat for the exam, with a success rate of 59% (72/122). To date, Switzerland has adopted the exam as their national training assessment and we expect that other countries will join Switzerland in the near future. Fostering the development and importance of the ECN requires that member states work to increase the academic and professional profile of the ECN within their countries. The ECN should be considered a 'quality mark' and a sign of high achievement in nephrology training in Europe. If holding the ECN becomes advantageous for employment or improving scientific careers, the number of candidates will increase and the sustainability of the ECN will be guaranteed. A recent, positive development is the pre-agreement between the UEMS Renal Section, UK Renal Association and Royal Colleges of the UK to adopt a unique pan-European exam beginning in 2020. However, any decision to commence the pan-European exam will depend, in part, on strong candidate enrolment for the ECN 2019 edition. Thus support of the national societies is crucial for the sustainability and growth of a European exam, because of their capacities to influence strategic policies in hospitals, universities and medical associations, with a longer-term aim to increase the professional recognition of the European exam. info:eu-repo/semantics/publishedVersion

Resumen: 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®) 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. Abstract: 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. Palabras clave: Osteoporosis, CKD-MBD, Densidad mineral ósea, Fracturas, FRAX, Enfermedad renal crónica, DEXA, Keywords: Osteoporosis, CKD-MBD, Bone mineral density, Fractures, FRAX, Chronic kidney disease, DEXA

Resumen: Antecedentes: Las alteraciones del metabolismo óseo y mineral son complicaciones frecuentes de los pacientes de hemodiálisis que presentan una gran variabilidad geográfica. Objetivos: El objetivo del presente estudio fue evaluar por primera vez dichas alteraciones en pacientes de hemodiálisis de Perú. Métodos: El estudio incluyó 1.551 pacientes de hemodiálisis de 55 centros concertados con el seguro social de salud de Perú, pertenecientes a la ciudad de Lima. De cada paciente se recogieron datos demográficos, comorbilidades, tratamientos y parámetros bioquímicos. Los valores de calcio, fósforo y PTH fueron categorizados según los rangos recomendados en las guías KDOQI y KDIGO. Resultados: La edad media de los pacientes fue de 59,5 ± 15,6, con tiempo medio en hemodiálisis de 58,0 ± 54,2 meses. Todos los pacientes se dializaban con una concentración de calcio en el líquido de diálisis de 3,5 mEq/l y el 68,9% recibían captores de fósforo (98,4% carbonato de calcio). Se observó un alto porcentaje de pacientes con calcio sérico por encima y fósforo sérico por debajo de los rangos recomendados en las guías KDOQI (32,8% y 37,3% respectivamente). Más de la mitad de los pacientes tenían valores de PTH por debajo de los rangos recomendados, tanto en KDOQI como en KDIGO (56,4% y 51,6% respectivamente). Conclusiones: Los pacientes incluidos en el presente estudio se caracterizaron por ser más jóvenes que los de otros estudios y por tener hipofosforemia y PTH suprimida, probablemente debido a una excesiva sobrecarga de calcio a través del líquido de diálisis y el empleo de captores de fósforo con calcio. Abstract: Background: Mineral and bone metabolism disorders are common complications in haemodialysis patients that present significant geographical variability. Objectives: The objective of this study was to assess these disorders for the first time in haemodialysis patients from Peru. Methods: The study included 1551 haemodialysis patients from 55 centres affiliated with the Social Health System of Peru in the city of Lima. Demographic data, comorbidities, treatments and biochemical parameters were collected from each patient. Serum calcium, phosphorus and PTH levels were categorised according to the recommended ranges in the KDOQI and KDIGO guidelines. Results: The mean age of the patients was 59.5 ± 15.6 years, with a mean time on haemodialysis of 58.0 ± 54.2 months. All patients were dialysed with a calcium concentration in the dialysis fluid of 3.5 mEq/l and 68.9% of patients were prescribed phosphate-binding agents (98.4% of them calcium carbonate). A high percentage of patients showed serum calcium above, and serum phosphorus below, the recommended ranges in the KDOQI guidelines (32.8% and 37.3%, respectively). More than half of the patients had serum PTH values below the recommended ranges of both the KDOQI and KDIGO guidelines (56.4% and 51.6%, respectively). Conclusions: Patients included in this study were younger than those from other studies and showed both hypophosphataemia and suppressed PTH, probably due to an excessive calcium overload through dialysis fluid and the use of calcium-containing phosphate binding agents. Palabras clave: Enfermedad renal crónica, Hemodiálisis, Calcio, Fósforo, Hormona paratiroidea, Keywords: Chronic kidney disease, Haemodialysis, Calcium, Phosphorus, Parathyroid Hormone

Background Uraemic cardiomyopathy, a process mainly associated with increased myocardial fibrosis, is the leading cause of death in chronic kidney disease patients and can be prevented by vitamin D receptor activators (VDRAs). Since some microRNAs (miRNAs) have emerged as regulators of the fibrotic process, we aimed to analyse the role of specific miRNAs in VDRA prevention of myocardial fibrosis as well as their potential use as biomarkers. Methods Wistar rats were nephrectomized and treated intraperitoneally with equivalent doses of two VDRAs: calcitriol and paricalcitol. Biochemical parameters, cardiac fibrosis, miRNA (miR-29b, miR-30c and miR-133b) levels in the heart and serum and expression of their target genes collagen I (COL1A1), matrix metalloproteinase 2 (MMP-2) and connective tissue growth factor (CTGF) in the heart were evaluated. Results Both VDRAs attenuated cardiac fibrosis, achieving a statistically significant difference in the paricalcitol-treated group. Increases in RNA and protein levels of COL1A1, MMP-2 and CTGF and reduced expression of miR-29b and miR-30c, known regulators of these pro-fibrotic genes, were observed in the heart of chronic renal failure (CRF) rats and were attenuated by both VDRAs. In serum, significant increases in miR-29b, miR-30c and miR-133b levels were observed in CRF rats, which were prevented by VDRA use. Moreover, vitamin D response elements were identified in the three miRNA promoters. Conclusions VDRAs, particularly paricalcitol, attenuated cardiac fibrosis acting on COL1A1, MMP-2 and CTGF expression, partly through regulation of miR-29b and miR-30c. These miRNAs and miR-133b could be useful serum biomarkers for cardiac fibrosis and also potential new therapeutic targets.

Inflammation is central to chronic kidney disease (CKD) pathogenesis and vascular outcomes, but the exact players remain unidentified. Since low density granulocytes (LDGs) are emerging mediators in inflammatory conditions, we aimed to evaluate whether LDGs may be altered in CKD and related to clinical outcomes as biomarkers. To his end, LDGs subsets were measured in peripheral blood by flow cytometry and confocal microscopy in 33 CKD patients undergoing peritoneal dialysis and 15 healthy controls (HC). Analyses were replicated in an additional cohort. DEF3 (marker of early granulopoiesis) gene expression on PBMCs was quantified by qPCR. Total CD15+ LDGs and both CD14lowCD16+ and CD14−CD16− subsets were expanded in CKD. The relative frequency of the CD14−CD16− subpopulation was higher among the CD15+ pool in CKD. This alteration was stable over-time. The increased CD14−CD16−CD15+ paralleled Kauppila scores and DEF3 expression, whereas no association was found with CD14lowCD16+ CD15+. Both subsets differed in their CD11b, CD10, CD35, CD31, CD62L, IFNAR1 and CD68 expression, FSC/SSC features and nuclear morphology, pointing to different origins and maturation status. In conclusion, LDGs were expanded in CKD showing a skewed distribution towards a CD14−CD16−CD15+ enrichment, in association with vascular calcification. DEF3 expression in PBMC can be a marker of LDG expansion. Fil: Rodríguez Carrio, Javier. Hospital Universitario Central de Asturias. Instituto de Investigación Sanitaria del Principado de Asturias (ISPA). Bone and Mineral Research Unit; España. Universidad de Oviedo; España Fil: Carrillo López, Natalia. Hospital Universitario Central de Asturias; España Fil: Ulloa, Catalina. Hospital Universitario Central de Asturias; España Fil: Seijo, Mariana. Hospital Universitario Central de Asturias; España. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay. Instituto de Inmunología, Genética y Metabolismo. Universidad de Buenos Aires. Facultad de Medicina. Instituto de Inmunología, Genética y Metabolismo; Argentina Fil: Rodríguez García, Minerva. Hospital Universitario Central de Asturias; España Fil: Rodríguez Suárez, Carmen. Hospital Universitario Central de Asturias; España Fil: Díaz-Corte, Carmen. Hospital Universitario Central de Asturias; España Fil: Cannata Andía, Jorge B.. Universidad de Oviedo; España. Hospital Universitario Central de Asturias; España Fil: Suárez, Ana. Universidad de Oviedo; España Fil: Dusso, Adriana. Hospital Universitario Central de Asturias; España

Emerging evidence suggests a role for 7-dehydrocholesterol reductase (DHCR7) in the crosstalk between cholesterol and vitamin D. Our aim was to evaluate the impact of vitamin D-related polymorphisms and DHCR7 levels in the association between vitamin D deficiency and altered lipid profile in rheumatoid arthritis (RA). Serum 25(OH)-vitamin D, DHCR7 levels and vitamin D-related polymorphisms (VDR-rs2228570, CYP27A1-rs933994, CYP2R1-rs10741657 and DHCR7-rs12785878) were analyzed in 211 RA patients,94 controls and in a prospective cohort of 13 RA patients undergoing TNFα-blockade. Vitamin D was decreased in RA (p

In chronic kidney disease (CKD), hyperphosphatemia-induced inflammation aggravates vascular calcification (VC) by increasing vascular smooth muscle cell (VSMC) osteogenic differentiation, ADAM17-induced renal and vascular injury, and TNFα-induction of neutral-sphingomyelinase2 (nSMase2) to release pro-calcifying exosomes. This study examined anti-inflammatory β-glucans efficacy at attenuating systemic inflammation in health, and renal and vascular injury favoring VC in hyperphosphatemic CKD. In healthy adults, dietary barley β-glucans (Bβglucans) reduced leukocyte superoxide production, inflammatory ADAM17, TNFα, nSMase2, and pro-aging/pro-inflammatory STING (Stimulator of interferon genes) gene expression without decreasing circulating inflammatory cytokines, except for γ-interferon. In hyperphosphatemic rat CKD, dietary Bβglucans reduced renal and aortic ADAM17-driven inflammation attenuating CKD-progression (higher GFR and lower serum creatinine, proteinuria, kidney inflammatory infiltration and nSMase2), and TNFα-driven increases in aortic nSMase2 and calcium deposition without improving mineral homeostasis. In VSMC, Bβglucans prevented LPS- or uremic serum-induced rapid increases in ADAM17, TNFα and nSMase2, and reduced the 13-fold higher calcium deposition induced by prolonged calcifying conditions by inhibiting osteogenic differentiation and increases in nSMase2 through Dectin1-independent actions involving Bβglucans internalization. Thus, dietary Bβglucans inhibit leukocyte superoxide production and leukocyte, renal and aortic ADAM17- and nSMase2 gene expression attenuating systemic inflammation in health, and renal injury and aortic calcification despite hyperphosphatemia in CKD. A grant to A.S.D. and M.J.M. from IRBLleida and Agrotecnio Research collaborative projects from the Consell Social at Lleida University supported initial work, Instituto de Salud Carlos III and co-funded by European Union (ERDF/FEDER) (FIS PI11/00259, PI14/01452, PI17/02181), Plan de Ciencia, Tecnología e Innovación 2013–2017 y 2018–2022 del Principado de Asturias (GRUPIN14-028, IDI-2018-000152), RedInRen from ISCIII (ISCIII-RETIC REDINREN RD16/0009). Investigator support included: NC-L by GRUPIN14-028 and IDI-2018-000152, LM-A by GRUPIN14-028, SP by FICYT; MVA and PV by Educational Grant 2 A/2015 from ERA-EDTA CKD-MBD Working Group; PV and AC by ERA-EDTA fellowships 2011 and 2012; JR-C by MINECO (“Juan de la Cierva” program, FJCI-2015-23849); A.S.D. by Asociación Investigación de Fisiología Aplicada. A.S.D. and M.J.M. are members of the Campus Iberus (Ebro Valley Campus of International Excellence).

The Renal Section of the European Union of Medical Specialists is working towards harmonization and optimization of nephrology training across Europe and its Mediterranean borders. In addition to the need for harmonization of the heterogeneous time dedicated to training, it is necessary to ensure that the learning environment is of a sufficiently high standard to develop skilled specialists. Thus, there is a need to review the core educational infrastructure and resources that should be provided to trainees in order to be considered centres of excellence for nephrology training. This review addresses most of the characteristics and attributes that constitute a high-calibre training centre of excellence, considering that a training centre might not represent a single institution, but a network of institutions that provide a coordinated and complete curriculum to the trainee. The training institution should provide, apart from the classical current nephrological facilities (clinical nephrology, haemodialysis, peritoneal dialysis and transplantation), a number of other complementary facilities, including immunology, nephropathology-with a dedicated and expert renal pathologist-all the specialities of general medicine and general surgery and, in particular, vascular surgery, radiology and interventional radiology specialist services (renal biopsy, renal ultrasound and permanent vascular access) and intensive care unit. In addition to clinical training, a training centre of excellence should offer research facilities to allow trainees the opportunity to be involved in epidemiological, clinical, translational or basic scientific research. The training centres should ideally hold a certification of training accreditation. If the European and its Mediterranean border countries wish to guarantee a high standard of training in nephrology, their national health services need to recognize their responsibility towards the importance of doctor training, providing enough time for educational activities and investing in the resources required for high-standard specialist training.

Background rheumatoid arthritis (RA) is associated with increased cardiovascular (CV) risk. Although vitamin D deficiency has been linked to CV disease in other conditions, studies in RA have yielded contradictory results and pointed to the involvement of additional factors. On the one hand, several genetic polymorphisms have been linked to vitamin D levels. Moreover, emerging evidence suggests a role for the enzyme DHCR7 in the crosstalk between cholesterol and vitamin D synthesis. Objectives to evaluate the effect of genetic polymorphisms and DHCR7 levels in the interaction between vitamin D and lipid profile in RA. Methods serum levels of vitamin D and DHCR7 were measured in 212 RA patients (2010 EULAR/ACR criteria) and 104 matched healthy controls (HC) by chemiluminescence and immunoassays, respectively. VDR rs2228750 and DHCR7 rs12785878 SNPs were studied by TaqMan Assays. The effect of vitamin D deficiency on clinical features was assessed by linear regression analyses adjusting for age, gender, seasonality, vitamin D supplementation and DMARD usage. Results decreased vitamin D was found in RA compared to HC (p 0.050). Decreased DHCR7 levels were found between RA and HC in winter/spring (p=0.008) but not in summer/autumn (p=0.116). RA patients with CV disease exhibited lower DHCR7 levels (p=0.012) than their CV-free counterparts. Moreover, the associations among DHCR7, vitamin D and HDL levels followed a seasonal pattern: DHCR7 was correlated to vitamin D levels in summer/autumn (r=0.441, p=0.004), where vitamin D was associated with both HDL levels (r=0.354, p=0.009) and total/HDL ratio (r=−0.393, p=0.003). A DHCR7 rs12785878-driven effect was observed for these associations. On the contrary, a weak correlation between HDL and vitamin D was found in winter/spring (r=0.215, p=0.014), where decreased DHCR7 was associated with age at onset (r=−0.285, p=0.006) and RF titre (r=−0.326, p=0.013). Conclusions the effect of vitamin D on the lipid profile is dependent on genetic polymorphisms. DHCR7 has a pivotal role in the interaction between vitamin D and lipid profile in RA. Seasonality and DHCR7-HDL axis may be novel mediators in the CV disease in RA. Disclosure of Interest None declared

Background In chronic kidney disease (CKD), increases in serum phosphate and parathyroid hormone (PTH) aggravate vascular calcification (VC) and bone loss. This study was designed to discriminate high phosphorus (HP) and PTH contribution to VC and bone loss. Methods Nephrectomized rats fed a HP diet underwent either sham operation or parathyroidectomy and PTH 1-34 supplementation to normalize serum PTH. Results In uraemic rats fed a HP diet, parathyroidectomy with serum PTH 1-34 supplementation resulted in (i) reduced aortic calcium (80%) by attenuating osteogenic differentiation (higher α-actin; reduced Runx2 and BMP2) and increasing the Wnt inhibitor Sclerostin, despite a similar degree of hyperphosphataemia, renal damage and serum Klotho; (ii) prevention of bone loss mostly by attenuating bone resorption and increases in Wnt inhibitors; and (iii) a 70% decrease in serum calcitriol levels despite significantly reduced serum Fgf23, calcium and renal 24-hydroxylase, which questions that Fgf23 is the main regulator of renal calcitriol production. Significantly, when vascular smooth muscle cells (VSMCs) were exposed exclusively to high phosphate and calcium, high PTH enhanced while low PTH attenuated calcium deposition through parathyroid hormone 1 receptor (PTH1R) signalling. Conclusions In hyperphosphataemic CKD, a defective suppression of high PTH exacerbates HP-mediated osteogenic VSMC differentiation and reduces vascular levels of anti-calcifying sclerostin.

Autologous and allogeneic hematopoietic stem cell transplantation (HSCT) is the treatment of choice for patients with some malignant and non-malignant hematological diseases. Advances in transplantation techniques and supportive care measures have substantially increased the number of long-term HSCT survivors. This has led to an increasing patient population suffering from the late effects of HSCT, of which, bone loss and its consequent fragility fractures lead to substantial morbidity. Altered bone health, with consequent fragility fractures, and chronic graft-versus-host disease (GVHD) are factors affecting long-term quality of life after HSCT. Hypogonadism, HSCT preparative regimens, nutritional factors, and glucocorticoids all contribute to accelerated bone loss and increased fracture risk. Management strategies should include bone mineral density examination, evaluation of clinical risk factors, and general dietary and physical activity measures. Evidence has accumulated permitting recommendations for more attentiveness to evaluation and monitoring of bone health, with appropriate application of osteoporosis pharmacotherapies to patients at increased risk of bone loss and fracture.

Since accelerated atherosclerosis has been reported in systemic lupus erythematosus (SLE), predictive biomarkers of cardiovascular disease (CVD) are needed. Among non-traditional risk factors, bone mineral density (BMD) has been related to CVD. However, its role in SLE remains controversial. This study aims to analyze the associations of subclinical atherosclerosis with traditional and non-traditional CV risk factors.In a cross-sectional study, atherosclerosis burden was compared between 112 female SLE patients and 31 controls. Plaque number and carotid intima-media wall thickness (cIMT) were assessed by ultrasonography. In a retrospective study, BMD determinations obtained 5-years before the ultrasonography assessment were analyzed in a subgroup of 62 patients. Plaque frequency was increased in SLE, even in patients without CV events or carotid wall thickening. cIMT was increased in patients with CVD, positively correlated with body mass index (BMI). Interestingly, a paradoxical effect of BMI on carotid parameters was observed. Whereas underweight patients (BMI 20) showed increased prevalence of carotid plaques with low cIMT, those with BMI 30 showed higher cIMT and plaque burden. Overweight patients (25 BMI30) exhibited both elevated cIMT and plaque number. BMI was an independent predictor of BMD. In our retrospective study, patients with either clinical or subclinical CVD exhibited lower BMD levels than their CV-free counterparts. A low lumbar spine BMD independently predicted CVD development after adjusting for confounders.SLE was associated with a higher subclinical atherosclerosis burden, a bimodal effect being observed for BMI. Decreased BMD can be a CV risk biomarker in SLE.

Background. Serum phosphate is a key parameter in the management of chronic kidney disease-mineral and bone disorder (CKD-MBD). The timing of phosphate measurement is not standardized in the current guidelines. Since the optimal range of these biomarkers may vary depending on the duration of the interdialytic interval, in this analysis of the Current management of secondary hyperparathyroidism: a multicentre observational study (COSMOS), we assessed the influence of a 2- (midweek) or 3-day (post-weekend) dialysis interval for blood withdrawal on serum levels of CKD-MBD biomarkers and their association with mortality risk. Methods. The COSMOS cohort (6797 patients, CKD Stage 5D) was divided into two groups depending upon midweek or post-weekend blood collection. Univariate and multivariate Cox's models adjusted hazard ratios (HRs) by demographics and comorbidities, treatments and biochemical parameters from a patient/centre database collected at baseline and every 6 months for 3 years. Results. There were no differences in serum calcium or parathyroid hormone levels between midweek and post-weekend patients. However, in post-weekend patients, the mean serum phosphate levels were higher compared with midweek patients (5.5 ± 1.4 versus 5.2 ± 1.4 mg/dL, P < 0.001). Also, the range of serum phosphate with the lowest mortality risk [HR ≤ 1.1; midweek: 3.5-4.9 mg/dL (95% confidence interval, CI: 2.9-5.2 mg/dL); post-weekend: 3.8-5.7 mg/dL (95% CI: 3.0-6.4 mg/dL)] showed significant differences in the upper limit (P = 0.021). Conclusion. Midweek and post-weekend serum phosphate levels and their target ranges associated with the lowest mortality risk differ. Thus, clinical guidelines should consider the timing of blood withdrawal when recommending optimal target ranges for serum phosphate and therapeutic strategies for phosphate control. © 2018 The Author(s).