HirokoSegawaDepartmentofMolecularNutri7on,Ins7tuteof

BiomedicalSciences,TokushimaUniversityGraduateSchool

KDIGOCKD-MBDImplementa7onSummitKeioPlazaHotelTokyo,Japan

InVivoResponsesofPhosphorus-basedFoodwithDifferent

FormsinMice

•  Dietaryphosphorusmanagementisimportantfornotonly

renalpa7entsbutalsohealthypeoplewithnormalkidney

func7on,becausephosphorusintakeisassociatedwith

osteoporo7cfractures,leOventricularmass,andallcause

mortality,eveninhealthypopula7ons.

•  Thedailyphosphateintakevarieswithageandgender.

•  Onaglobalscale,therearequitesignificantdifferences

indietcomposi7onstobeconsidered.

Grains19.02%

Potates1.46%

Sugars&sweeteners0.00%

Soy7.07% Nuts,seeds

0.83%

Vegetables7.90%

Fruits1.66%

Mushroom1.46%Algae

0.62%

Seafood16.74%Meat,poultry

11.43%

Eggs6.55%

Dairyproducts12.79%

Oils0.00%

Bakery2.39%

Beverages2.39%

Seasoning7.38%

Supplementarynutri7on0.31%

Cited; 2010 National Health and Nutrition Survey, Table 9

No.1

No.3

No.2

Sources of phosphorus in Japanese food supply, 2010

Male; 4153, Female; 4662

0

200

400

600

800

1000

1200

1400

1600

2012 2013 2014 2015 2016

Male(>20yearsold)Female(>20yearsold)

Phosp

horu

s (m

g /da

y )

Na>onalHealthandNutri>onSurveyJapan　

AnnualChangesintheMeanPhosphorusIntake(aged20yearsandover)(2012to2016)

Cited; 2012 - 2016 National Health and Nutrition Survey,

0

200

400

600

800

1000

1200

1400

1600

2012 2013 2014 2015 2016

Male(>20yearsold)Female(>20yearsold)

Phosp

horu

s (m

g /da

y )

Na>onalHealthandNutri>onSurveyJapan　

AnnualChangesintheMeanPhosphorusIntake(aged20yearsandover)(2012to2016)

AdequateIntake；1000mg/day

DietaryReferenceIntakesforJapanese(2015)

AdequateIntake； 800mg/day

Cited; 2012 - 2016 National Health and Nutrition Survey,

•  Assessmentofdietaryphosphorusiscomplicatedby

inaccuraciesinmostnutrientcomposi7ondatabasesdueto

theextensiveandvarieduseofphosphorus-containing

foodaddi7ves.

•  Intakefromprocessedfoodsispar7cularlyobscuredbythe

factthatnutri7onallabelsarenotrequiredtoreportthe

phosphoruscontentoffood.

•  Dietaryphosphorusintakecouldbees7matedfrom24-hurine

collec7onbyurinaryphosphorusexcre7ondividedbyphosphorus

absorp7onrate(65%).

•  Phosphorusabsorp7onratesinpreviousstudiesvarywidelypossiblyduetofactorsassociatedwithitsregula7on,suchasthetypeof

phosphorus,othermineralsandinterindividualvaria7oninprior

nutrientstatusortransit7me.

•  Dietaryrecords(DR)areatypeofself-reporteddietaryassessment

method.

•  Althoughwidelyused,DRhaveinherentproblemsandrequirement

forpar7cipantliteracy.

•  Theseproblemscannotbeavoidedinna7onalrepresenta7ve

surveys.

0

200

400

600

800

1000

1200

1400

1600

2012 2013 2014 2015 2016

Male(>20yearsold)Female(>20yearsold)

AnnualChangesintheMeanPhosphorusIntake

(aged20yearsandover)(2012to2016)

Dietaryphosphorusintakebydietaryrecordsand24-hoururinecollec7oninJapaneseadults.

Studydesign•  Thisobserva7onalstudywasbasedondatafromacrosssec7onal

mul7centersurveyconductedinFebruaryandMarch2013.

•  Thesurveytargetedhealthymenandwomenaged20–69years

livingthroughoutJapan.

•  Thetotalnumberofpar7cipantswas395menand396women.

ShinozakiN.etal.EuropeanJournalofClinicalNutri7on(2018)72:517–525

•  Bodyweightandweremeasured

•  BMIwascalculated.

•  Informa7ononage,educa7on,medicalhistory,currentmedica7onuse,

physicalac7vity,andsmoking

•  Es7matesofphysicalac7vitywerecalculated.

•  Dietaryintakewasassessedby4-daysemi-weighteddietaryrecords.

•  Urinecollec7onswereperformedontwonon-consecu7vedays.

•  Atotalof161menand161womenaged20–69yearscompleteda4-day

dietaryrecordsandtwo24-hurinecollec7on.•  Allanalyseswereperformedusingthesta7s7calsoOwarepackageSAS

version9.4.•  Two-sidedP-values<0.05wereconsideredsta7s7callysignificant.

ShinozakiN.etal.EuropeanJournalofClinicalNutri7on(2018)72:517–525

Table1Characteris7csof322apparentlyhealthymenandwomenpar7cipantsaged20–69years,2013

ShinozakiN.etal.EuropeanJournalofClinicalNutri7on(2018)72:517–525

Men WomenbyDietaryrecord 1176 1021

byUC 1393 1082

020040060080010001200140016001800

Phosphorusintakees7matedbyUrineCollec7onwashigherthanthates7matedbyDietaryrecord

ShinozakiN.etal.EuropeanJournalofClinicalNutri7on(2018)72:517–525

P<0.0001

P=0.008*

*

Dietaryph

osph

orusintake

(mg/day)

n=161

n=161

200 60

Men WomenbyDietaryrecord 1176 1021

byUC 1393 1082

020040060080010001200140016001800

P<0.0001

P=0.008�*�

*�

Dietaryph

osph

orusintake

(mg/day)�

AdequateIntake(AI)；1000mg/day

DietaryReferenceIntakesforJapanese(2015)

AdequateIntake(AI)； 800mg/day

PhosphorusintakewassufficientlyhigherthanAdequateintakeinDRI.

ShinozakiN.etal.EuropeanJournalofClinicalNutri7on(2018)72:517–525

200 60

Mono-phosphateex)DisodiumhydrogenphosphateTrisodiumhydrogenphosphate

Poly-phosphatex)Potassiumpolyphosphate

Calciumdihydrogenpyrophosphate

Phosphatecontainingfood

Organicphosphate Inorganicphosphate

Foodaddi?ves

Orthophosphoricacid Pyrophosphoricacid triphosphate

NaturalsourcesAnimals,vegetables

Dietaryphosphorus

Organicphosphorus Inorganicphosphorus

AnimalproteinVegetableprotein

Foodaddi7ves

Mono-phosphatesalts Poly-phosphatesalts

•  EnhanceFlavor•  ImproveColor•  Extendtheshelflife•  Moisturereten>on•  Improvetexture•  Smoothness•  Binding•  etc.

Phosphorusaddi7vesareusedforthesefunc7ons……

Infla>ng

Moisturereten>on

Binding

Improvetexture

ü  DicalciumPhosphateü  Hexametaphosphateü  MonocalciumPhosphateü  PhosphoricAcidü  Ca,Na,orK-polyphosphate

CommonPhosphorusAddi7ves

processedmeat

3Na+

?

HPO42-

Pathways for phosphate absorption in the small intestine

Basal

Apical

Inorganic monophosphate

Paracellular pathway

Transcellular pathway

Absorption system

Intestinal epithelial cell

Facilitatetransport

Transporter

Dietary Pi Digestion systemProtein

polyphosphate

3Na+

?

HPO42-

Basal

Apical

Inorganic mono phosphate

Transcellular pathway

Absorption system

NaPi2b

Transcellular pathway

2Na+

Transcellular pathway

?

PiT1/2

Paracellular transport is a major system of intestinal Pi absorption

DietaryPi

Npt2b

HPO42-

HPO42-

HPO42-

?

3Na+

Pit-1NHE3

Na+

H+

Na+ H2PO4-

P P P

P

P

P PP P

P

P

P

P

P

P

PP

P P

P

??

?

21

JAmSocNephrol.2017

NHE3inhibitorreducesphosphateabsorp7onfromthegut

JAmSocNephrol,2015

ü apicalsideiIntes7ne,colon,kidney….)ü Na+,H+exchangeü playsamajorroleintransepithelial

absorp7onofNa+andwaterü modulatestheabsorp7onofother

nutrients

NHE3/SLC9A3(Sodium+/hydrogen

exchanger3) Na+

H+

NHE3

H+

PepT1

Di,tripep>des

H+ pep>des Na+

Na/KATPase

K+

aminoacids Aminoacidtransporters

Lumen

Bloodaminoacids

Na+

Tenapanorisdiscoveredanddevelopedforthepa7entswithIBS-C.hrp://www.ardelyx.com/what-we-do/

Inaddi7on,hrp://www.ardelyx.com/what-we-do/

DietaryPi

Npt2b

HPO42-

HPO42-

HPO42-

?

3Na+

Pit-1NHE3

Na+

H+

Na+ H2PO4-

P P P

P

P

P PP P

P

P

P

P

P

P

PP

P P

P

claudins

HPO42-

claudinsParacellularPipathway

? ?

?

?

Transcellular and Paracellular Pi transport

ü  JNutrSciVitaminol(Tokyo).1999Oct;45(5):595-608.Comparisonofvariousphosphatesaltsasthedietaryphosphorussourceonnephrocalcinosisandkidneyfunc>oninrats.MatsuzakiH1,KikuchiT,KajitaY,MasuyamaR,UeharaM,GotoS,SuzukiK.

ü  BiosciBiotechnolBiochem.2001Apr;65(4):928-34.Greatereffectofdietarypotassiumtripolyphosphatethanofpotassiumdihydrogenphosphateonthenephrocalcinosisandproximaltubularfunc>oninfemaleratsfromtheintakeofahigh-phosphorusdiet.MatsuzakiH1,MasuyamaR,UeharaM,NakamuraK,SuzukiK.

Mono-phosphateex)DisodiumhydrogenphosphateTrisodiumhydrogenphosphate

Poly-phosphatex)Potassiumpolyphosphate

Calciumdihydrogenpyrophosphate

Phosphatecontainingfood

Organicphosphate Inorganicphosphate

Foodaddi?ves

Orthophosphoricacid Pyrophosphoricacid triphosphate

NaturalsourcesAnimals,vegetables

Polyphosphatesalthavemoreharmfuleffectsthanthoseofmonophosphatesaltonbonephysiologyandrenalfunc7on.

27? Basal

Apical

Inorganic monophosphate

Dietary Pi

Poly-P

?

transporter

Gastrointestinal phosphate handling

Intestinal epithelial cell

Pi Pi

？

Pi

Pi

Pi

Mono-P

Poly-P

Pi

Pi

OrganicInorganic

Mono-P

Pi

Pi

Pi Pi

AnimalC57BL6J,5weeksofage♂　TestdietGroup1.  Low Pi diet 2.  Control Pi diet 3.  Monophosphate HP 4.  Polyphosphate HP

AnimalsandDiet

Pi Pi

Pi

Pi Pi

Mono-PHighphosphatediet

Pi

Poly-PHighphosphatediet

Diet 100 g �g�LP CP HP1 HP2

AIN93G modified Mix 59.5 59.5 59.5 59.5Egg White 20 20 20 20

AIN93G modified Mineral Mix 1.5645 1.56451.56451.5645

Sucrose 10.4371 7.88715.25214.7421CaCO3 1.4984 1.49841.49841.4984

KH2PO4 or K5P3O10 0 2.55 5.185 5.695Soy Bean Oil 7 7 7 7

Total 100 100 100 100

MonoHP PolyHP

Timeschedule

0 7 28 32 33 3435�

�days�

Metaboliccage

Sacrificed

5weeks

Start5weeksofage 10weeksofage

Pi Pi

Pi

Pi Pi

Mono-PHighphosphatediet

Pi

Poly-PHighphosphatediet

1.  Low Pi diet 2.  Control Pi diet 3.  Monophosphate HP 4.  Polyphosphate HP

Testdiet

0

5

10

15

20

25

30

35

40

LP CP HP1 HP20

1

2

3

4

5

6

7

LP CP HP１ HP２

0

2

4

6

8

10

LP CP HP１ HP２

a

a,b

0

1

2

3

4

5

LP CP HP1 HP2

a,b

a aa

a

aa

aa a

Pla

sma

Pi (

mg/

dl)

Pla

sma

Ca

(mg/

dl)

Urin

e P

i (m

g/da

y)

Urin

e C

a(m

g/da

y)

0

50

100

150

200

250

300

LP HP1 HP2

FGF2

3 (p

g/m

L)

0 20 40 60 80

100 120 140 160 180

LP HP1 HP2

a aa

PTH

(pg/

mL)

MonoHP

PolyHP

MonoHP

PolyHP

MonoHP

PolyHP

MonoHP

PolyHP

MonoHP

PolyHP

MonoHP

PolyHP

LP CP MonoHP PolyHP

LP CP HP1 HP2

Massontrichromestain

VonKossaCalciumstain

Polyphosphatedietinducedrenalfibrosisandcalcifica7on.

MonoHP PolyHP

Whatisthedifferencebetweenmono-Pdietandpoly-Pdiet?

Pi Pi

Pi

Pi Pi

Mono-PHighphosphatediet

Pi

Poly-PHighphosphatediet

Pi Pi Pi

Proxim

alintes7ne

ATP(n

M)

ATP:SubstrateforIAPIntes7nalalkalinephosphatase

(IAP)

0

0.2

0.4

0.6

0.8

1

1.2

HP1 HP2

0

0.5

1

1.5

2

2.5

HP1 HP2

Proxim

alintes7ne

p-NP

(mmol/m

gprotein/min)

HP1 HP2HP1 HP2

＊ ＊

MonoHP

PolyHP

MonoHP

PolyHP

Iden>fica>onofspecifictargetsforthegutmucosaldefensefactorintes>nalalkalinephosphataseKathrynT.Chen,1,2MadhuS.Malo,1AngelaK.Moss,1SkyeZeller,3PaulJohnson,3FarzadEbrahimi,1GolamMostafa,1SayedaN.Alam,1SundaramRamasamy,1H.ShawWarren,3ElizabethL.Hohmann,3andRichardA.Hodin1

Microbiota–hostinterac7onandmodula7onbydietarynutrients.

Uremictoxin

Nutrients2017,9,489;doi:10.3390/nu9050489modified

Processedbymicrobiota

Growth:Prolifera7onofmicrobiotadependenton

specificnutrients

Absorbedinthegut

Uptakebymicrobiota

Processedbyhost

Growth/Tissueandfunc7onmaintenance

L-carni7ne,choline/phospha7dylcholine,tryptophanandtyrosine…Pi..

UremictoxinOr

Uremictoxinpre

Nutrients

Hostwaste Microbialwaste

　

MonophosphateHP PolyphosphateHP

Pi Pi

PiPiATP

IAP

IAP

IAPIAP

degrada7on

microbiota microbiota

ATP

ATPATP

種類分布

Type,Numberchange

BloodPiHigh BloodPiHigh

Pi Pi

Hypothesis

　

Uremictoxin

ü  JapanesepeopletakehigherdietaryphosphorusthantheadequateintakeinDRI.

ü  Phosphorusintakees7matedbyUrineCollec7onwashigherthanthates7matedbyDietary

record.

ü  Hiddenphosphorus

ü  Considerphosphoruscontentandtheform.

Summary