FGF23 is a cardiovascular toxin in CKD

FGF23 is a cardiovascular toxin in CKD

Chronic kidney disease (CKD) is a serious health problem that involves gradual loss of kidney function. The major cause of death in CKD patients is cardiovascular disease is triggered by the cardiovascular toxins fibroblast growth factor (FGF23) and phosphate.

Declining kidney  function leads to elevated  serum phosphate levels which are regulated by the phophaturic hormone FGF23 in CKD patients.  In later stages of chronic kidney disease, access FGF23 and phosphate levels lead to increased cardiovascular disease and mortality.  Ongoing experimental studies are identifying  novel therapeutic strategies in order to prevent toxicity of FGF23 and hyperphosphatemia in CKD patients.

FGF23 is a cardiovascular toxin in chronic kidney disease

FGF23 and Phosphate-Cardiovascular Toxins in CKD.

Vogt I, Haffner D, Leifheit-Nestler M. Toxins (Basel). 2019 Nov 6;11(11):647. doi: 10.3390/toxins11110647. PMID: 31698866; PMCID: PMC6891626.

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FGF23 and Phosphate-Cardiovascular Toxins in CKD  full text link

Abstract

Elevated levels of fibroblast growth factor 23 (FGF23) and phosphate are highly associated with increased cardiovascular disease and mortality in patients suffering from chronic kidney disease (CKD). As the kidney function declines, serum phosphate levels rise and subsequently induce the secretion of the phosphaturic hormone FGF23. In early stages of CKD, FGF23 prevents the increase of serum phosphate levels and thereby attenuates phosphate-induced vascular calcification, whereas in end-stage kidney disease, FGF23 fails to maintain phosphate homeostasis. Both hyperphosphatemia and elevated FGF23 levels promote the development of hypertension, vascular calcification, and left ventricular hypertrophy by distinct mechanisms. Therefore, FGF23 and phosphate are considered promising therapeutic targets to improve the cardiovascular outcome in CKD patients. Previous therapeutic strategies are based on dietary and pharmacological reduction of serum phosphate, and consequently FGF23 levels. However, clinical trials proving the effects on the cardiovascular outcome are lacking. Recent publications provide evidence for new promising therapeutic interventions, such as magnesium supplementation and direct targeting of phosphate and FGF receptors to prevent toxicity of FGF23 and hyperphosphatemia in CKD patients.

RELATED PUBLICATIONS

 Fibroblast Growth Factor-23-A Potential Uremic Toxin.

Kuczera P, Adamczak M, Wiecek A Toxins (Basel). 2016 Dec 8;8(12):369. doi: 10.3390/toxins8120369. PMID: 27941640; PMCID: PMC5198563.

 Abstract

Fibroblast growth factor-23 (FGF23) is a circulating member of the FGF family produced mainly by the osteocytes and osteoblasts that can act as a hormone. The main action of FGF23 is to lower phosphatemia via the reduction of urinary phosphate reabsorption and the decrease of 1,25(OH)₂-D generation in the kidney. In the course of chronic kidney disease (CKD), plasma FGF23 concentration rises early, most probably to compensate the inability of the deteriorating kidneys to excrete an adequate amount of phosphate. However, this comes at the cost of FGF23-related target organ toxicity. Results of clinical studies suggest that elevated plasma FGF23 concentration is independently associated with the increased risk of CKD progression, occurrence of cardio-vascular complications, and mortality in different stages of CKD. FGF23 also contributes to cardiomyocyte hypertrophy, vascular calcification, and endothelial dysfunction. The impact of FGF23 on heart muscle is not dependent on Klotho, but rather on the PLCγ-calcineurin-NFAT (nuclear factor of activated T-cells) pathway. Among the factors increasing plasma FGF23 concentration, active vitamin D analogues play a significant role. Additionally, inflammation and iron deficiency can contribute to the increase of plasma FGF23. Among the factors decreasing plasma FGF23, dietary phosphate restriction, some intestinal phosphate binders, cinacalcet (and other calcimimetics), and nicotinamide can be enumerated. Anti-FGF23 antibodies have also recently been developed to inhibit the action of FGF23 in target organs. Still, the best way to normalize plasma FGF23 in maintenance hemodialysis patients is restoring kidney function by successful kidney transplantation.

Effect of different phosphate binders on fibroblast growth factor 23 levels in patients with chronic kidney disease: a systematic review and meta-analysis of randomized controlled trials.

Zhao SJ, Wang ZX, Chen L, Wang FX, Kong LD. Ann Palliat Med. 2022 Apr;11(4):1264-1277. doi: 10.21037/apm-21-1943. Epub 2021 Nov 2. PMID: 34775773.

 Simultaneous management of disordered phosphate and iron homeostasis to correct fibroblast growth factor 23 and associated outcomes in chronic kidney disease.

Courbon G, Martinez-Calle M, David V. Curr Opin Nephrol Hypertens. 2020 Jul;29(4):359-366. doi: 10.1097/MNH.0000000000000614. PMID: 32452919; PMCID: PMC7769207.