The western pattern diet is rich not only in fat and calorie but also in phosphate. Negative impacts of excessive fat and calorie intake on health are widely accepted, whereas potential harms of excessive phosphate intake are poorly recognized. Here we show the mechanism by which dietary phosphate damages the kidney. When phosphate intake was excessive relative to the functioning nephron number, circulating fibroblast growth factor-23 (FGF23), a hormone that increases phosphate excretion per nephron, was increased to maintain phosphate homeostasis. FGF23 suppressed phosphate reabsorption in renal tubules and thus raised the phosphate concentration in the tubular fluid. Once it exceeded a threshold, microscopic particles containing calcium phosphate crystals appeared in the tubular lumen, which damaged tubular cells through binding to Toll-like receptor-4 expressed on them. Persistent tubular damage induced interstitial fibrosis, reduced the nephron number, and further boosted FGF23 to trigger a deterioration spiral leading to progressive nephron loss. In humans, progression of chronic kidney disease (CKD) ensued when the serum FGF23 level exceeded 53 pg/mL. The present study identified the calcium phosphate particles in the renal tubular fluid as an effective therapeutic target to decelerate nephron loss during the course of aging and CKD progression.
Kazuhiro Shiizaki, Asako Tsubouchi, Yutaka Miura, Kinya Seo, Takahiro Kuchimaru, Hirosaka Hayashi, Yoshitaka Iwazu, Marina Miura, Batpurev Battulga, Nobuhiko Ohno, Toru Hara, Rina Kunishige, Mamiko Masutani, Keita Negishi, Kazuomi Kario, Kazuhiko Kotani, Toshiyuki Yamada, Daisuke Nagata, Issei Komuro, Hiroshi Itoh, Hiroshi Kurosu, Masayuki Murata, Makoto Kuro-o