Research Article

CORRELATION BETWEEN FIBROBLAST GROWTH FACTOR-23

SERUM AND FRACTIONAL EXCRETION OF PHOSPHATE URINE IN
PREDIALYSIS CHRONIC KIDNEY DISEASE

Vika Wirdhani, Yenny Kandarini, Wiradewi Lestari

Internal Medicine Department. Faculty of Medicine Udayana University /
Sanglah Teaching Hospital Denpasar

ABSTRACT
Background: Fibroblast Growth Factor-23 (FGF-23), has role in regulating
phospate homeostasis and could be an early marker of Chronic Kidney Disease
(CKD) mineral and bone disorders. Fractional excretion of phosphate (FEPi) urine
is the proportion of phosphate which is filtrated by kidney and excreted through
urine. There is an increasing FGF-23 serum level and FEPi urine in predialysis
CKD. Currently, there is no study reported in evaluating a correlation between
FGF-23 serum level and FEPi urine in Indonesian setting. This study aimed to
find correlation betwen FGF-23 serum level and FEPi urine in predialysis CKD.
Methods: An observational and cross-sectional study was conducted in Sanglah
Hospital from October 2014 until April 2015. The investigator recruited 75
predialysis CKD patients by consecutive sampling. Criteria inclusion of this study
were predialysis CKD stage 2,3, and 4 patient aged range 18-65 years old.
Patients who got vitamin D, phosphate binder, calcimimetic therapy, and have
been diagnosed with malabsorption syndrome and malignancy were excluded
from this study. All participants were taken informed consent. The correlation
between FGF-23 serum level and FEPi urine was analyzed using Spearman
correlation test. Results: Fifty four out of 75 samples were male (72%) and 21
(28%) were female. Nineteen (25,3%) were CKD stage 2, 43 (57,3%) were CKD
stage 3, and 13 (17,3%) were CKD stage 4. Median FGF-23 levels was 108,7
(13,6-1226,2) RU/ml. Median FEPi urine was 24,3 (4,04-65,9)%. This study
showed positive and significant correlation between FGF-23 and FEPi urine (r =
0,44; p < 0,001). Conclusions: FGF-23 serum level has moderate correlation with
FEPi urine in predialysis CKD.

Keywords: FGF-23, predialysis, phosphate

INTRODUCTION has been detected earlier in CKD (2).

Mineral and bone metabolism Recent clinical studies demonstrate a
disorder is one of CKD high fractional renal phosphate
complication, for example disorder excretion despite the presence of
of calsium metabolism, phosphate normophosphatemia in early CKD.
and parathyroid hormone (1). Early detection and intervention
Disorder of phosphate metabolism plays an important role to decrease

1

mortality in CKD-MBD (1). FGF-23
serum level elevated in stage 2 and
most in stage 3 and 4 CKD (3,4).
Fibroblast growth factor-23
stimulates phosphaturia as a response
of phosphate overload. It works at
renal tubules by increasing urinary
phosphate excretions, deacreasing
serum calcitriol level, maintaning
normal level of phosphate serum
(4,5,6). FGF-23 serum level rise
progressively as eGFR declines
beginning in CKD stage 2 (3). There
is an increasing FGF-23 serum level
and FEPi urine in predialysis CKD.
FEPi urine is percentage of
phosphate filtrated by kidney and
excreted thorugh urine (5) and one of
phosphate handling in the kidney (6).
Currently, there is no study
reported in evaluating a correlation
between FGF-23 serum level and
FEPi urine in Indonesian setting.
Increased concentrations of FGF-23
and FEPi urine are observed in
predialysis CKD, in which increased
FGF-23 and FEPi urine are
associated with more rapid disease
progression, and increased morbidity
and mortality. Therefore can be used
as an early intervention for abnormal
phosphate metabolism in CKD. This
study aimed to find correlation
betwen FGF-23 serum level and
FEPi urine in predialysis CKD.
METHODS
Study Design
This study is an cross-
sectional study. Study participants
were recruited from outpatient and
inpatient in Sanglah General
2
Hospital from October 2014 until
March 2015. This study used
consecutive sampling methods.
Patients were eligible if they were
18-65 years old with estimated GFR
15-89 ml/minute or clinically stable
patients with phase 2,3, and 4 CKD.
eGFR was calculated from
Cockcroft- Gault formula. Exclusion
criteria included current treatment
with activated vitamin D analog, oral
phosphorus binders or phosphorus
supplements, treatment with
calcimimetic, history or laboratory
evidence of malabsorption syndrome
and malignan
Study Protocol
Subjects were recorded
medical and treatment history. They
determined to take blood for
measurement phosphate, calcium,
and creatinine serum and 24-hour
urine collections for measurement of
phosphate and creatinine urine.
Blood and urine samples for
measurement of laboratory test were
immediately processed in Prodia
Laboratory using standard
commercial assays. FGF-23
concentrations were measured using
enzyme-linked immunosorbent assay
(ELISA), Immunotopics. Fractional
excretion of phosphate (FEPi) urine
derived from the equation; FEPi =
(phosphate urine x creatinin
serum)/(phosphate serum x creatinin
urine) x 100% (7). This study was
approved by the Ethical Board
Review Medical Faculty Udayana
University/Sanglah Teaching
 3

Hospital Denpasar, Research and Hypertension 37 (49,3%)

Development Division; No Diabetes melitus 30 (40%)
Serum Phosphate 3,48 ± 0,86
1317/UN.14.2/Litbang/2014. All
(mg/dL)
subjects provided written and Urine Phosphate (mg/dL) 500 (100-1300)
informed consent. Serum Creatnin (mg/dL) 1,52 (0,58-
4,13)
Statistical Analysis
Urine Creatinin (mg/dL) 922,7 ± 410,2
Statistical analysis were GFR (ml/menit) 50,1 ± 20
performed using Statistics Program FGF-23 (RU/ml) 108,7 (13,6-
1226,2)
for Social Science v.15,0. (SPSS Inc,
FEPi urin (%) 24,3 (4,04-
USA). Numerical results were 65,9)
expressed as means ± S.D, Calsium (mg/dL) 9,23 ± 0,7
frequency, median, minimum- CKD stage
maximum range, and normality test Stage 2 19 (25,3%)
Stage 3 43 (57,3%)
for every variable. Spearman
Stage 4 13 (17,3%)
correlation was used because FGF- Mean ± SD are shown; Hb, Hemoglobin; FGF-
23 and FEPi urine were not normally 23, Fibroblast Growth Factor-23; GFR,
Glomerular Filtration Rate; FEPi, Fraction
distributed. A P-value less than 0,05 Excretion Phosphate; CKD, Chronic Kidney;
was considered significant. BWI, Body Wight Index

RESULTS
Subject Characteristics
The subject characteristics
were listed in Table 1. This study
was conducted in Sanglah Hospital
from October 2014 until April 2015.
Fifty four out of 75 samples were
male (72%) and 21 (28%) were
female. Nineteen (25,3%) were CKD
stage 2, 43 (57,3%) were CKD stage
Figure 1. Graphic level of FGF-23 serum and
3, and 13 (17,3%) were CKD stage FEPi urine FGF-23 in Predialysis CKD
4. Median FGF-23 levels was 108,7
(13,6-1226,2) RU/ml (Figure 1).

Table 1. Subject Characteristics

Variabel Mean ± SD
Median (min-
max)
Jenis kelamin
Man 54 (72%)
Woman 21 (28%)
Age (yr) 50 ± 10,8
BWI (kg/m2) 23,51 ± 3,3

FEPi_urin
60.00
40.00
20.00
0.00
0.0 200.0 400.0 600.0
FGF_23
Figure 2. Scatter plot diaphgram correlation
between FGF-23 serum level and FEPi urine in
predialysis CKD
This study showed positive
and significant correlation between
FGF-23 and FEPi urine (r = 0,44; p <
0,001) (Figure 2).
DISCUSSON
Median FGF-23 serum level
and FEPi urine in this study was
108,7 (13,6-1226,2) RU/mL and 24,3
(4,04–65,9)% respectively. Result
from previous study had median
level serum FGF-23 140 (81-236)
RU/mL and FEPi urine 32 (25-44)%
(8), serum FGF-23 145 (96-239)
RU/mL and FEPi urine 25 (19–35)%
(9), serum FGF-23 102 (64-164)
RU/mL and FEPi urine 26±13%
(10). The diffference result from
other study probably because of
sample size, subject characteristics,
and genetic. Vitamin D and PTH
serum level were not evaluated in
this study.
4
Patients with CKD stage 2 to
3 had normal phosphate serum level,
while FGF-23 serum level and FEPi
urine increasing in predialysis CKD.
It has been proposed that FGF-23
rises as an appropiate compensatroy
response to phosphate retention due
to impaired renal excretion (renal
injury) (9,11) or due to reduced
r = 0,44
p = 0,000
renal expression of Klotho that
induces resistance of FGF-23. Klotho
is a receptor for FGF-23. FGF-23
800.0 1000.0 1200.0 promote renal phosphate wasting
through internalization of the sodium
phosphate cotransporter IIa and IIc at
the proximal tubular apical
membrane (8,9,11,12).
Normal level of FEPi urine is
15-20% (5). Our study showed FEPi
urine was increased in preadialysis
CKD confirmed with previous study
(13). FEPi urine is the indicator of
renal phosphate excretion (14,16).
As kidney function decreasing so
does FEPi urine at the tubules. An
increased urinary phosphate
excretion may help to maintain
phosphate homeostasis in early CKD
(6), showed in this study.
FGF-23 serum and FEPi
urine are elevated early in most CKD
stage 2-4. Both are inversely
correlated with decreasing GFR
(8,12,13,15,16). Our study showed
FGF-23 serum level has moderate
correlation with FEPi urine in
predialysis CKD (r=0,44, p=0,000)
consistent with other study by Sakan
dkk., (2014) r=0,401, p<0,0001,
Bech dkk., (2015) r=0,36, p<0,001,
Isakova dkk. (2011) r=0,25,
 5

p<0,0001, dan Dominguez dkk. serum level and FEPi urine between
(2013) r=0,21, p<0,05. every stage of CKD In the future,
High fractional renal prospective study will be needed to
phosphate excretion is due to maintain prove the relationship between FGF-
normal phosphate serum level (16). 23 and FEPi urine. In conclusion,
FGF-23 induces phosphaturia paralel FGF-23 serum level has positive
with increasing FEPi urine (8,14). correlation with FEPi urine in
The mechanism through increasing predialysis CKD.
phosphate excretion per nephron that
makes urinary phosphate excretion References
increase (1). FGF-23 induces 1. Kuro-o M. A phosphate-
phophaturia through internalisation centric paradigm for
and degradation sodium-phosphate pathophysiology and therapy
cotransporter, NPT2a; at the of chronic kidney disease.
proximal tubules; inhibits Kidney International
parathyroid hormone secretion; and Supplements. 2013;3:420-
426.
decreases levels of calcitriol (1,25D),
2. Wahl P, Wolf M. FGF23 in
reduce the efficiency of phosphate Chronic Kidney Disease.
absorption in the gut maintain Endocrine FGFs and
normal phosphate serum level Klothos, ed Makoto Kuro-o.
(3,4,8,16). Landes Bioscience and
Renal dysfunction initially Springer Science.
induces reduction in renal expresion 2012;p.102-125.
3. Isakova T. Fibroblast Growth
of Klotho. Secretion of FGF-23 into
Factor 23 and Adverse
the circulation is enhanced by renal Clnical Outcomes in Chronic
to maintain normal level phosphate Kidney Disease. Curr Opin
serum. The resultant rise in FGF-23 Nephrol Hipertens.
increased FEPi and reduced level of 2012;21(3):334-340
vitamin D. This would in turn lead to 4. Wolf M. Update on fibroblast
normalization of serum phosphate gowth factor 23 in chronic
kidney disease. Kidney Int.
level. In advanced CKD, level of
2012;82(7):737-747
Klotho decrease so FGF-23 can not 5. Bagnis CI, Karie S, Deray G,
compensate for the renal failure- Essig M. Hypohosphatemia:
induced phosphate retention. an easy strategy for diagnosis
Consequently, phosphate serum is and treatment in HIV
elevated (12). patients. International
Medical Press. 2009;14:481-
Weakness of our study is a 488.
cross sectional setting. We did not 6. Guitierrez O, Isakova T,
measure Klotho, parathyroid Rhee E, Shah A, Holmes J,
hormone and 1,25- Collerone G. Fibroblast
growth factor-23 mitigates
dihydroxyvitamin-D and the
hyperhosphatemia but
diifference of increased FGF-23

accentuates calcitriol
deficiency. Clin J Am Soc
Nephrol. 2005;7:581-587.
7. Kestenbaum B, Drueke TB.
Disorders of Calcium,
phosphate, and magnesium
metabolism. In : Floege J,
Johnson RJ, Feehally J,
editors. Comprehensive
Clinical Nephrology 4th .Ed.
Missouri: Saunders.
2010;p.969-983.
8. Bech AP, Krijger AB, Zuilen
AD, Bots ML, Jan AJG,
Blankestjin PJ, dkk. Impact
of fractional phosphate
excretion on the relation of
FGF23 with outcome in CKD
patients. J Nephrol. 2015;
28:477-484.
9. Isakova T, Wahl P, Vargas G,
Gutierrez OM, Scialla J,
Huiliang X. FGF23, PTH and
phosphorus metabolism in the
chrpinic renal insufficiency
kohort. Kindey Int.
2011;79(12):1370-1378
10. Seiler S, Rogacev KS, Roth
HJ, Shafein P, Emrich I,
Neuhaus S. Associations of
FGF-23 and sKlotho with
cardiovascular outcomes
among patients with CKD
stages 2-4. Clin J Am Soc
Nephrol. 2014;9:1049-1058
11. Heine GH, Seiler S, Fliser D.
FGF-23: the Rise of a novel
cardiovascular risk in CKD.
Nephrol Dial Transplant.
2012; 27:3072-3081
12. Sakan H, Nakatani K, Asai
O, Imura A, Tanaka T,
Yoshimoto S. Reduced Renal
α-Klotho Expression in CKD
patients and its Effect on
Renal Phosphate Handling
and Vitamin D Metabolism,
PLOS ONE. 2014;9(1):1-9.
6
13. Craver L, Dusso A, Martinez-
Alonso M, Sarro F,
Valdivielso JM, Fernandez E.
A Low Fractional Excretion
of Phosphate/FGF23 ratio is
associated with Severe
Abdominal Aortic
Calcification Stage 3 and 4
Chronic Kidney Disease
Patients. BMC Nephrology.
2013;221(14):1-12.
14. Dominguez JR, Shlipak MG,
Whooley MA, Joachim H.
Fractional excretion of
phosphorus Modifies the
association between
fibroblast growth factor-23
and outcomes. J Am Soc
Nephrol. 2013; 24(4):647-
654
15. Houston J, Smith K, Isakova
T, Sowden N, Wolf M,
Gutierrez OM. Associations
of dietary phosphorus intake,
urinary phosphate excretion
and fibroblast growth factor
23 with vascular stiffness in
chronic kidney disease. J Ren
Nutr. 2013;23(1):12-20.
16. Evenopoel P, Meijers B,
Viane L, dkk. Fibroblast
growth factor-23 in early
chronic kidney disease:
additional support in favor of
a phosphate-centric paradigm
for the pathogenesis of
secondary
hyperparathyroidsm. Clin J
Am Soc Nephrol.
2010;5:1268-1276