The predictive value of Klotho polymorphism, in addition to classical markers of CKD-MBD, for left ventricular hypertrophy in haemodialysis patients

  • Branislav ApostolovićEmail author
  • Tatjana Cvetković
  • Nikola Stefanović
  • Svetlana Apostolović
  • Marija Anđelković Apostolović
  • Branka Mitić
  • Radmila Veličković Radovanović
  • Karolina Paunović
  • Aleksandra Ignjatović
  • Mina Cvetković
  • Nataša Stević
  • Dusica Pavlović
Nephrology - Original Paper



Cardiovascular events are the major reasons for mortality in haemodialysis patients. Fibroblast growth factor 23 (FGF23), Klotho protein and G-395A Klotho gene polymorphism have been associated with effects on the cardiovascular system. Our study investigates the interrelationship between Klotho protein gene variations, mineral–bone metabolism and left ventricular hypertrophy in patients undergoing chronic haemodialysis programme.

Materials and methods

Patients (n = 142) were genotyped for G-395A Klotho gene. Components of mineral–bone metabolism, classical and non-classical (FGF23, Klotho and vitamin D) as well as echocardiographic examination were determined. Predictive models were designed to determine the significance of Klotho gene variations and mineral–bone metabolism components for left ventricle hypertrophy (LVH).


A-allele carriers were longer on haemodialysis (p = 0.033), and had higher phosphorus levels (p = 0.016) while the level of Klotho protein was significantly lower (p = 0.001) compared to non-A-allele carriers. The best gains were achieved upon addition of allele A, and all three new markers; the AUC made significant improvement from 0.596 to 0.806 (p < 0.001), and improved net reclassification for 82.1% (95% CI 42.9–121.3%).


The genetic background of A-allele carriers of the G-395A Klotho gene polymorphism increases the susceptibility patients to haemodialysis. A-allele carriers are at a higher risk for the development of cardiovascular complications. The addition of non-classical to classical mineral metabolism components improves prediction power to LVH.


Klotho gene polymorphism FGF23 Klotho LVH Haemodialysis Predictive models 



This study was supported by the research grant from the Ministry of Education, Science and Technological Development, Republic of Serbia—Project Number 41018.

Compliance with ethical standards

Conflict of interest

The authors report no declarations of interest.


  1. 1.
    Saran R, Robinson B, Abbott KC, Agodoa LY, Albertus P, Ayanian J, Balkrishnan R, Bragg-Gresham J, Cao J, Chen JL, Cope E, Dharmarajan S, Dietrich X, Eckard A, Eggers PW, Gaber C, Gillen D, Gipson D, Gu H, Hailpern SM, Hall YN, Han Y, He K, Hebert H, Helmuth M, Herman W, Heung M, Hutton D, Jacobsen SJ, Ji N, Jin Y, Kalantar-Zadeh K, Kapke A, Katz R, Kovesdy CP, Kurtz V, Lavalee D, Li Y, Lu Y, McCullough K, Molnar MZ, Montez-Rath M, Morgenstern H, Mu Q, Mukhopadhyay P, Nallamothu B, Nguyen DV, Norris KC, O’Hare AM, Obi Y, Pearson J, Pisoni R, Plattner B, Port FK, Potukuchi P, Rao P, Ratkowiak K, Ravel V, Ray D, Rhee CM, Schaubel DE, Selewski DT, Shaw S, Shi J, Shieu M, Sim JJ, Song P, Soohoo M, Steffick D, Streja E, Tamura MK, Tentori F, Tilea A, Tong L, Turf M, Wang D, Wang M, Woodside K, Wyncott A, Xin X, Zang W, Zepel L, Zhang S, Zho H, Hirth RA, Shahinian V (2017) US renal data system 2016 annual data report: epidemiology of kidney disease in the United States. Am J Kidney Dis 69(3 Suppl 1):A7–A8. CrossRefGoogle Scholar
  2. 2.
    De Nicola L, Zoccali C (2016) Chronic kidney disease prevalence in the general population: heterogeneity and concerns. Nephrol Dial Transplant 31(3):331–335. CrossRefGoogle Scholar
  3. 3.
    Hruska KA, Sugatani T, Agapova O, Fang Y (2017) The chronic kidney disease—mineral bone disorder (CKD-MBD): advances in pathophysiology. Bone 100:80–86. CrossRefGoogle Scholar
  4. 4.
    Blau JE, Collins MT (2015) The PTH-Vitamin D-FGF23 axis. Rev Endocr Metab Disord 16(2):165–174. CrossRefGoogle Scholar
  5. 5.
    Hu MC, Shi M, Cho HJ, Adams-Huet B, Paek J, Hill K, Shelton J, Amaral AP, Faul C, Taniguchi M, Wolf M, Brand M, Takahashi M, Kuro OM, Hill JA, Moe OW (2015) Klotho and phosphate are modulators of pathologic uremic cardiac remodeling. J Am Soc Nephrol JASN 26(6):1290–1302. CrossRefGoogle Scholar
  6. 6.
    Nakao M, Yokoyama K, Yamamoto I, Matsuo N, Tanno Y, Ohkido I, Hayakawa H, Ikeda M, Yamamoto H, Hosoya T (2014) Risk factors for encapsulating peritoneal sclerosis in long-term peritoneal dialysis: a retrospective observational study. Ther Apher Dial 18(1):68–73. CrossRefGoogle Scholar
  7. 7.
    Jimbo R, Shimosawa T (2014) Cardiovascular risk factors and chronic kidney disease-FGF23: a key molecule in the cardiovascular disease. Int J Hypertens 2014:381082. CrossRefGoogle Scholar
  8. 8.
    Hu MC, Kuro-o M, Moe OW (2012) Secreted klotho and chronic kidney disease. Adv Exp Med Biol 728:126–157. CrossRefGoogle Scholar
  9. 9.
    Xie J, Cha SK, An SW, Kuro OM, Birnbaumer L, Huang CL (2012) Cardioprotection by Klotho through downregulation of TRPC6 channels in the mouse heart. Nat Commun 3:1238. CrossRefGoogle Scholar
  10. 10.
    Hu MC, Kuro-o M, Moe OW (2013) Klotho and chronic kidney disease. Contrib Nephrol 180:47–63. CrossRefGoogle Scholar
  11. 11.
    Luo L, Hao Q, Dong B, Yang M (2016) The Klotho gene G-395A polymorphism and metabolic syndrome in very elderly people. BMC Geriatr 16:46. CrossRefGoogle Scholar
  12. 12.
    Hao Q, Ding X, Gao L, Yang M, Dong B (2016) G-395A polymorphism in the promoter region of the KLOTHO gene associates with reduced cognitive impairment among the oldest old. Age (Dordrecht, Netherlands) 38(1):7. CrossRefGoogle Scholar
  13. 13.
    Turpeinen U, Hohenthal U, Stenman UH (2003) Determination of 25-hydroxyvitamin D in serum by HPLC and immunoassay. Clin Chem 49(9):1521–1524CrossRefGoogle Scholar
  14. 14.
    Shimoyama Y, Nishio K, Hamajima N, Niwa T (2009) KLOTHO gene polymorphisms G-395A and C1818T are associated with lipid and glucose metabolism, bone mineral density and systolic blood pressure in Japanese healthy subjects. Clin Chim Acta Int J Clin Chem 406(1–2):134–138. CrossRefGoogle Scholar
  15. 15.
    Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, Flachskampf FA, Foster E, Goldstein SA, Kuznetsova T, Lancellotti P, Muraru D, Picard MH, Rietzschel ER, Rudski L, Spencer KT, Tsang W, Voigt JU (2015) Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 28(1):1–39. CrossRefGoogle Scholar
  16. 16.
    Robin X, Turck N, Hainard A, Tiberti N, Lisacek F, Sanchez J-C, Müller M (2011) pROC: an open-source package for R and S + to analyze and compare ROC curves. BMC Bioinf 12(1):77. CrossRefGoogle Scholar
  17. 17.
    Steyerberg EW, Vickers AJ, Cook NR, Gerds T, Gonen M, Obuchowski N, Pencina MJ, Kattan MW (2010) Assessing the performance of prediction models: a framework for traditional and novel measures. Epidemiol (Camb MA) 21(1):128–138. CrossRefGoogle Scholar
  18. 18.
    Ignjatovic A, Stojanovic M, Milosevic Z, Andelkovic Apostolovic M (2018) Progress of statistical analysis in biomedical research through the historical review of the development of the Framingham score. Irish J Med Sci 187(3):639–645. CrossRefGoogle Scholar
  19. 19.
    DeLong ER, DeLong DM, Clarke-Pearson DL (1988) Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics 44(3):837–845CrossRefGoogle Scholar
  20. 20.
    Steyerberg EW, Vergouwe Y (2014) Towards better clinical prediction models: seven steps for development and an ABCD for validation. Eur Heart J 35(29):1925–1931. CrossRefGoogle Scholar
  21. 21.
    Zeng QY, Xia ZY, Tong YS, Sun L, Mou HB, Chen R, Bi GY, Liu CH (2018) The association of klotho gene polymorphism and the regulation of calcium-phosphate metabolism disorders in patients with ESRD. Nephrology (Carlton, VIC).
  22. 22.
    Ko GJ, Lee EA, Jeon US, Pyo HJ, Chin HJ, Chae DW, Kim S, Kwon YJ (2012) The association of Klotho polymorphism with disease progression and mortality in IgA nephropathy. Kidney Blood Pressure Res 36(1):191–199. CrossRefGoogle Scholar
  23. 23.
    Wang HL, Xu Q, Wang Z, Zhang YH, Si LY, Li XJ, Yang QH, Xiao H (2010) A potential regulatory single nucleotide polymorphism in the promoter of the Klotho gene may be associated with essential hypertension in the Chinese Han population. Clin Chim Acta Int J Clin Chem 411(5–6):386–390. CrossRefGoogle Scholar
  24. 24.
    Kuro OM (2011) Phosphate and Klotho. Kidney Int 79121:S20–S23. CrossRefGoogle Scholar
  25. 25.
    Chonchol M, Greene T, Zhang Y, Hoofnagle AN, Cheung AK (2016) Low Vitamin D and high fibroblast growth factor 23 serum levels associate with infectious and cardiac deaths in the HEMO study. J Am Soc Nephrol JASN 27(1):227–237. CrossRefGoogle Scholar
  26. 26.
    Kuro OM (2017) The FGF23 and Klotho system beyond mineral metabolism. Clin Exp Nephrol 21(Suppl 1):64–69. CrossRefGoogle Scholar
  27. 27.
    Grabner A, Amaral AP, Schramm K, Singh S, Sloan A, Yanucil C, Li J, Shehadeh LA, Hare JM, David V, Martin A, Fornoni A, Di Marco GS, Kentrup D, Reuter S, Mayer AB, Pavenstadt H, Stypmann J, Kuhn C, Hille S, Frey N, Leifheit-Nestler M, Richter B, Haffner D, Abraham R, Bange J, Sperl B, Ullrich A, Brand M, Wolf M, Faul C (2015) Activation of cardiac fibroblast growth factor receptor 4 causes left ventricular hypertrophy. Cell Metab 22(6):1020–1032. CrossRefGoogle Scholar
  28. 28.
    Mogelvang R, Biering-Sorensen T, Jensen JS (2015) Tissue Doppler echocardiography predicts acute myocardial infarction, heart failure, and cardiovascular death in the general population. Eur Heart J Cardiovasc Imaging 16(12):1331–1337. Google Scholar
  29. 29.
    Faul C, Amaral AP, Oskouei B, Hu MC, Sloan A, Isakova T, Gutierrez OM, Aguillon-Prada R, Lincoln J, Hare JM, Mundel P, Morales A, Scialla J, Fischer M, Soliman EZ, Chen J, Go AS, Rosas SE, Nessel L, Townsend RR, Feldman HI, St John Sutton M, Ojo A, Gadegbeku C, Di Marco GS, Reuter S, Kentrup D, Tiemann K, Brand M, Hill JA, Moe OW, Kuro OM, Kusek JW, Keane MG, Wolf M (2011) FGF23 induces left ventricular hypertrophy. J Clin Investig 121(11):4393–4408. CrossRefGoogle Scholar
  30. 30.
    Foley RN, Parfrey PS, Harnett JD, Kent GM, Martin CJ, Murray DC, Barre PE (1995) Clinical and echocardiographic disease in patients starting end-stage renal disease therapy. Kidney Int 47(1):186–192CrossRefGoogle Scholar
  31. 31.
    Levin A, Thompson CR, Ethier J, Carlisle EJ, Tobe S, Mendelssohn D, Burgess E, Jindal K, Barrett B, Singer J, Djurdjev O (1999) Left ventricular mass index increase in early renal disease: impact of decline in hemoglobin. Am J Kidney Dis 34(1):125–134. CrossRefGoogle Scholar
  32. 32.
    Touchberry CD, Green TM, Tchikrizov V, Mannix JE, Mao TF, Carney BW, Girgis M, Vincent RJ, Wetmore LA, Dawn B, Bonewald LF, Stubbs JR, Wacker MJ (2013) FGF23 is a novel regulator of intracellular calcium and cardiac contractility in addition to cardiac hypertrophy. Am J Physiol Endocrinol Metab 304(8):E863–E873. CrossRefGoogle Scholar
  33. 33.
    Tripepi G, Kollerits B, Leonardis D, Yilmaz MI, Postorino M, Fliser D, Mallamaci F, Kronenberg F, Zoccali C (2015) Competitive interaction between fibroblast growth factor 23 and asymmetric dimethylarginine in patients with CKD. J Am Soc Nephrol JASN 26(4):935–944. CrossRefGoogle Scholar
  34. 34.
    Drechsler C, Pilz S, Obermayer-Pietsch B, Verduijn M, Tomaschitz A, Krane V, Espe K, Dekker F, Brandenburg V, Marz W, Ritz E, Wanner C (2010) Vitamin D deficiency is associated with sudden cardiac death, combined cardiovascular events, and mortality in haemodialysis patients. Eur Heart J 31(18):2253–2261. CrossRefGoogle Scholar
  35. 35.
    Chen S, Law CS, Grigsby CL, Olsen K, Hong TT, Zhang Y, Yeghiazarians Y, Gardner DG (2011) Cardiomyocyte-specific deletion of the vitamin D receptor gene results in cardiac hypertrophy. Circulation 124(17):1838–1847. CrossRefGoogle Scholar
  36. 36.
    Xiang W, Kong J, Chen S, Cao LP, Qiao G, Zheng W, Liu W, Li X, Gardner DG, Li YC (2005) Cardiac hypertrophy in vitamin D receptor knockout mice: role of the systemic and cardiac renin-angiotensin systems. Am J Physiol Endocrinol Metab 288(1):E125–E132. CrossRefGoogle Scholar
  37. 37.
    Goldsmith DJ, Covic A, Sambrook PA, Ackrill P (1997) Vascular calcification in long-term haemodialysis patients in a single unit: a retrospective analysis. Nephron 77(1):37–43. CrossRefGoogle Scholar
  38. 38.
    Hu MC, Shi M, Gillings N, Flores B, Takahashi M, Kuro OM, Moe OW (2017) Recombinant alpha-Klotho may be prophylactic and therapeutic for acute to chronic kidney disease progression and uremic cardiomyopathy. Kidney Int 91(5):1104–1114. CrossRefGoogle Scholar

Copyright information

© Springer Nature B.V. 2019

Authors and Affiliations

  • Branislav Apostolović
    • 1
    • 2
    Email author
  • Tatjana Cvetković
    • 1
    • 2
  • Nikola Stefanović
    • 1
  • Svetlana Apostolović
    • 1
    • 4
  • Marija Anđelković Apostolović
    • 1
    • 3
  • Branka Mitić
    • 1
    • 2
  • Radmila Veličković Radovanović
    • 1
    • 2
  • Karolina Paunović
    • 2
  • Aleksandra Ignjatović
    • 1
    • 3
  • Mina Cvetković
    • 1
    • 2
  • Nataša Stević
    • 1
  • Dusica Pavlović
    • 1
  1. 1.Faculty of MedicineUniversity of NišNišSerbia
  2. 2.Clinic of NephrologyClinical Center NišNišSerbia
  3. 3.Department of StatisticsPublic Health Institute NišNišSerbia
  4. 4.Clinic for Cardiovascular DiseasesClinical Centre NišNišSerbia

Personalised recommendations