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Papadimitriou DT, Bothou C, Dermitzaki E, Alexopoulos A, Mastorakos G. Treatment of alopecia totalis/universalis/focalis with vitamin D and analogs: Three case reports and a literature review. World J Clin Pediatr 2021; 10:192-199. [PMID: 34868895 PMCID: PMC8603638 DOI: 10.5409/wjcp.v10.i6.192] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 04/18/2021] [Accepted: 07/06/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Alopecia areata (AA) is an inflammatory disease with autoimmune, environmental, and inherited components directed at the hair follicle, either limited to patchy hair loss over the scalp (Focalis, AF), total loss of scalp hair (Totalis, AT), or total loss of both scalp and body hair (Universalis, AU). Despite multiple treatment modalities, no therapy exists. Vitamin D deficiency in patients with AA/AT/AF influences disease severity and duration, inversely correlating with inflammation histologically.
CASE SUMMARY Three girls presented with AT (P1), AU (P2), and AF (P3) at the ages of 1, 5, and 5 years, respectively. For P1-P2, all available treatments implemented for 2 years had failed. We started an initial 6-mo repletion with oral cholecalciferol 2000/4000 IU/d, with no apparent effect. Then we attempted immunomodulation using oral calcitriol and its analog paricalcitol. On calcitriol, 0.5 mcg/d P1 regrew hair within 6 mo. After 4 years, a relapse with loss of eyebrow hair was resolved after doubling the calcitriol dose to 0.5 mcg × 2/d; the results have been maintained for 6 years to date. On calcitriol, 0.25 mcg × 3/d P2 led to the development of asymptomatic hypercalcemia-hypercalciuria, which was immediately resolved by switching to paricalcitol 2 mcg × 3/d; mild tolerable hypercalciuria was maintained. Hair regrowth was observed at 6 mo, stabilizing only as fur at 12 mo. AF in P3 was resolved completely within 3 mo on a daily high dose (8000 IU) of cholecalciferol.
CONCLUSION Vitamin D may have immunomodulating therapeutic impact on AT/AU/AF, which needs to be explored with further pilot clinical trials.
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Affiliation(s)
- Dimitrios T Papadimitriou
- Department of Pediatric-Adolescent Endocrinology and Diabetes, Athens Medical Center, Athens 15125, Greece
- Endocrine Unit, Aretaieion University Hospital, Athens 11528, Greece
| | - Christina Bothou
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ), University of Zurich (UZH), CH-8091 Zurich, Switzerland
| | - Eleni Dermitzaki
- Department of Pediatric-Adolescent Endocrinology and Diabetes, Athens Medical Center, Athens 15125, Greece
| | - Alexios Alexopoulos
- Special Unit of Dermatology, First Department of Pediatrics, National and Kapodistrian University of Athens Medical School, Agia Sofia Children's Hospital, Athens 11527, Greece
| | - George Mastorakos
- Endocrine Unit, Aretaieion University Hospital, Athens 11528, Greece
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Ni LH, Yuan C, Song KY, Wang XC, Chen SJ, Wang LT, Zhang YX, Liu H, Liu BC, Tang RN. Efficacy and safety of cinacalcet and active vitamin D in the treatment of secondary hyperparathyroidism in patients with chronic kidney disease: a network meta-analysis. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:322. [PMID: 31475192 DOI: 10.21037/atm.2019.05.84] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background We conducted a network meta-analysis (NMA) to evaluate the efficacy and safety of cinacalcet, active vitamin D and cinacalcet plus active vitamin D in the treatment of secondary hyperparathyroidism (SHPT) in patients with chronic kidney disease (CKD). Methods A systematic literature search was performed using the Cochrane Library, PubMed, EMBASE, Web of Science, Google Scholar, China National Knowledge Internet (CNKI) and Wanfang databases. In total, eight randomized controlled trials (RCTs) with 1,443 patients were eligible for this meta-analysis. Pairwise meta-analysis was performed to evaluate the compliance of intact parathyroid hormone (iPTH), Ca, P, etc., and the mortality and safety of cinacalcet plus active vitamin D and active vitamin D alone. Then, NMA was used to estimate the safety and efficacy of the administration of active vitamin D and different drugs in the control group. Results The results of the pairwise meta-analysis revealed that compared with active vitamin D monotherapy, cinacalcet plus active vitamin D did not improve the survival of patients but significantly improved the blood calcium compliance rate [relative risk (RR) =1.82, 95% confidence interval (CI): 1.51-2.21, P<0.00001]. Furthermore, it is worth noting that compared with the corresponding incidence with other treatments, the incidence of vomiting was significantly increased with cinacalcet plus active vitamin D treatment (RR =2.07, 95% CI: 1.18-3.65, P=0.01). Through direct and indirect comparisons, the NMA revealed the following results: (I) compared with oral or intravenous (IV) administration of vitamin D, the solely oral administration of active vitamin D increased mortality, and (II) cinacalcet monotherapy increased the risk of hypocalcemia, and that risk was even higher for cinacalcet plus active vitamin D. However, the results should be treated with caution because the prediction interval (PrI) crossed the invalid line. Conclusions This pairwise meta-analysis and NMA provided a comprehensive analysis of the currently utilized CKD-SHPT treatment interventions. This network identified some highly ranked interventions through analyses that were included in a small number of trials; these interventions merit further examination on a larger scale in the context of well-designed RCTs.
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Affiliation(s)
- Li-Hua Ni
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing 210009, China
| | - Cheng Yuan
- Department of Radiation and Medical Oncology, Zhongnan Hospital, Wuhan University, Wuhan 430071, China
| | - Kai-Yun Song
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing 210009, China
| | - Xiao-Chen Wang
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing 210009, China
| | - Si-Jie Chen
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing 210009, China
| | - Li-Ting Wang
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing 210009, China
| | - Yu-Xia Zhang
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing 210009, China
| | - Hong Liu
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing 210009, China
| | - Bi-Cheng Liu
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing 210009, China
| | - Ri-Ning Tang
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing 210009, China.,Nanjing Lishui People's Hospital, Zhongda Hospital Lishui Branch, Nanjing 210009, China
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Czaya B, Seeherunvong W, Singh S, Yanucil C, Ruiz P, Quiroz Y, Grabner A, Katsoufis C, Swaminathan S, Abitbol C, Rodriguez-Iturbe B, Faul C, Freundlich M. Cardioprotective Effects of Paricalcitol Alone and in Combination With FGF23 Receptor Inhibition in Chronic Renal Failure: Experimental and Clinical Studies. Am J Hypertens 2019; 32:34-44. [PMID: 30329020 DOI: 10.1093/ajh/hpy154] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 10/13/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND In uremic animals, vitamin D receptor (VDR) agonists like paricalcitol (Pc) attenuate cardiac hypertrophy, but this effect has not been replicated consistently in humans with chronic kidney disease. Elevated fibroblast growth factor 23 (FGF23) levels cause cardiac hypertrophy with activation of the myocardial calcineurin/nuclear factor of activated T cell (NFAT) axis and may antagonize the cardioprotective effects of VDR agonist therapy. We hypothesized that the effectiveness of Pc may depend on the prevailing circulating levels of FGF23 and could be potentiated by the combined administration of a pan-FGF23 receptor (FGFR) blocker agent (PD173074). METHODS In rats with 5/6 nephrectomy treated with Pc or PD173074 or both agents concurrently, myocardial mRNA expression of renin-angiotensin system, VDR, FGFR4, and calcineurin/NFAT target genes was determined. In adolescents on hemodialysis, we analyzed sequential echocardiograms, blood pressures and serial FGF23 measurements, and their relations to the cumulative administered dose of parenteral Pc. RESULTS The ratio of Pc dose/plasma levels of FGF23 correlated inversely (P < 0.005) with the cardiac mass in uremic rats and in hemodialysis patients, independently of hypertension. Despite persistently elevated FGF23 levels and myocardial FGFR4 activation, Pc suppressed upregulated myocardial calcineurin/NFAT target genes, and the effects were amplified by coadministration of PD173074. CONCLUSIONS The beneficial effects of Pc on uremic cardiac hypertrophy are counterbalanced by the increased FGF23 levels. Blockade of FGF23-mediated signaling increased the Pc-induced suppression of the myocardial calcineurin/NFAT system. Higher doses of Pc should be considered in the treatment of patients with uremic cardiomyopathy.
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Affiliation(s)
- Brian Czaya
- Katz Family Drug Discovery Center and Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
- Division of Nephrology, Department of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Wacharee Seeherunvong
- Division of Pediatric Nephrology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Saurav Singh
- Katz Family Drug Discovery Center and Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Christopher Yanucil
- Katz Family Drug Discovery Center and Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
- Division of Nephrology, Department of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Phillip Ruiz
- Department of Surgery and Immunopathology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Yasmir Quiroz
- Hospital Universitario, Servicio de Nefrologia y Laboratorio de Inmunobiologia, Instituto Venezolano de Investigaciones Científicas (IVIC)-Zulia, Maracaibo, Venezuela
| | - Alexander Grabner
- Katz Family Drug Discovery Center and Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Chryso Katsoufis
- Division of Pediatric Nephrology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Sethuraman Swaminathan
- Division of Pediatric Cardiology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Carolyn Abitbol
- Division of Pediatric Nephrology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Bernardo Rodriguez-Iturbe
- Hospital Universitario, Servicio de Nefrologia y Laboratorio de Inmunobiologia, Instituto Venezolano de Investigaciones Científicas (IVIC)-Zulia, Maracaibo, Venezuela
| | - Christian Faul
- Katz Family Drug Discovery Center and Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
- Division of Nephrology, Department of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Michael Freundlich
- Division of Pediatric Nephrology, University of Miami Miller School of Medicine, Miami, Florida, USA
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Acharya N, Doherty DR, Barrowman N, Maharajh G, Girolamo T, O'Hearn K, McNally JD. Calcitriol trend following pediatric cardiac surgery and association with clinical outcome. Pediatr Res 2018; 84:254-260. [PMID: 29899389 DOI: 10.1038/s41390-018-0049-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 04/27/2018] [Accepted: 04/27/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Consistent with accepted practice in stable ambulatory populations, the majority of ICU research has evaluated vitamin D status using a single blood 25-hydroxyvitamin D (25(OH)D) level. Only a limited number of ICU studies have measured the active hormone, 1,25-dihydroxyvitamin D (calcitriol) and none have used change in calcitriol levels to evaluate axis functioning. The objective of this study was to describe the impact of Congenital Heart Disease (CHD) surgery on calcitriol levels and evaluate the relationship between change in postoperative levels and clinical course. METHODS Secondary analysis of a prospective cohort study of 56 children undergoing surgery for CHD. RESULTS Mean calcitriol levels dropped from 122.3 ± 69.1 pmol/L preoperatively to 65.3 ± 36.5 pmol/L (p < 0.0001) at PICU admission. The majority (61%, n = 34) were unable to increase calcitriol levels in the 48 h immediately following surgery. Post operative trend in calcitriol was inversely related to cardiovascular dysfunction, fluid requirements, ventilatory support and PICU length of stay (p < 0.01). CONCLUSION CHD patients had significant dysfunction of the vitamin D axis immediately postoperatively, demonstrated by both a significant intraoperative decline in calcitriol and inability to increase levels. Interventional research will be required to determine whether the use of calcitriol, in addition to cholecalciferol, reduces postoperative illness severity.
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Affiliation(s)
- Nina Acharya
- Department of Pediatrics, University of Ottawa, Ottawa, Canada.,Division of Nutritional Science, Cornell University, Ithaca, NY, USA
| | - Dermot R Doherty
- Pediatric Intensive Care Unit, The Children's University Hospital, Dublin, Ireland
| | - Nick Barrowman
- Clinical Research Unit, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Gyaandeo Maharajh
- Division of Cardiovascular Surgery, University of Ottawa, Ottawa, Canada
| | - Tara Girolamo
- Division of Cardiovascular Surgery, University of Ottawa, Ottawa, Canada
| | - Katie O'Hearn
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - J Dayre McNally
- Department of Pediatrics, University of Ottawa, Ottawa, Canada.
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Successful Treatment of Severe Atopic Dermatitis with Calcitriol and Paricalcitol in an 8-Year-Old Girl. Case Rep Pediatr 2018; 2018:9643543. [PMID: 30034905 PMCID: PMC6035840 DOI: 10.1155/2018/9643543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 06/06/2018] [Indexed: 11/20/2022] Open
Abstract
Atopic dermatitis (AD) is a chronic inflammatory disease affecting children and adolescence. The traditional therapeutic options for AD, including emollients topically and immune modulatory agents systemically focusing on reducing skin inflammation and restoring the function of the epidermal barrier, are proven ineffective in many cases. Several studies have linked vitamin D supplementation with either a decreased risk to develop AD or a clinical improvement of the symptoms of AD patients. In this report, we present a girl with severe AD who under adequate supplementation with cholecalciferol was treated with calcitriol and subsequently with paricalcitol. She had significant improvement—almost healing of her skin lesions within 2 months, a result sustained for more than 3 years now. Because of hypercalciuria as a side effect from calcitriol therapy, treatment was continued with paricalcitol, a vitamin D analogue used in secondary hyperparathyroidism in chronic kidney disease. Calcitriol therapy may be considered as a safe and efficacious treatment option for patients with severe AD, particularly for those with refractory AD, under monitoring for possible side effects. Treatment with paricalcitol resolves hypercalciuria, is safe, and should be further investigated as an alternative treatment of atopic dermatitis and possibly other diseases of autoimmune origin.
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Freundlich M, Abitbol CL. Oral paricalcitol: expanding therapeutic options for pediatric chronic kidney disease patients. Pediatr Nephrol 2017; 32:1103-1108. [PMID: 28451892 DOI: 10.1007/s00467-017-3675-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 04/07/2017] [Indexed: 12/18/2022]
Abstract
The complex pathophysiology of progressive chronic kidney disease (CKD) and the development of mineral and bone disorder, abbreviated as CKD-MBD, is of vital importance to a pediatric patient. Paricalcitol, the 19 nor-1,25(OH)2D2 analogue was shown to be effective and safe in the treatment of secondary hyperparathyroidism (SHPT) in adults almost two decades ago. It also significantly improved survival in dialysis patients compared to the standard calcitriol. The successful treatment of CKD-MBD in children is essential if they are to grow and survive into adulthood. It can be argued that it is more important for children with CKD than adults since they have early and prolonged disease risk exposure. In this issue of Pediatric Nephrology, Webb et.al. report a dual trial of the safety, efficacy, and pharmacokinetics of paricalcitol in children aged 10-16 years with moderate but significant efficacy in meeting the endpoint of >30% decrease in parathyroid hormone (PTH) levels from baseline with minimal adverse events. Much more research needs to be done to expand and develop clinical pharmaceutical trials in the use of paricalcitol in children, especially in the younger age categories. This current study has done much to open the doors for future studies, with the caveat that it has been long coming and much more needs to be done to compensate for this delay in the treatment of children with CKD-MBD and cardiovascular and renal disease progression.
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Affiliation(s)
- Michael Freundlich
- Division of Pediatric Nephrology, University of Miami Miller School of Medicine, P.O. Box 016960 (M714), Miami, FL, 33101, USA
| | - Carolyn L Abitbol
- Division of Pediatric Nephrology, University of Miami Miller School of Medicine, P.O. Box 016960 (M714), Miami, FL, 33101, USA.
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7
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Webb NJA, Lerner G, Warady BA, Dell KM, Greenbaum LA, Ariceta G, Hoppe B, Linde P, Lee HJ, Eldred A, Dufek MB. Efficacy and safety of paricalcitol in children with stages 3 to 5 chronic kidney disease. Pediatr Nephrol 2017; 32:1221-1232. [PMID: 28332096 PMCID: PMC5440538 DOI: 10.1007/s00467-017-3579-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 12/22/2016] [Accepted: 12/28/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Elevated intact parathyroid hormone (iPTH) levels can contribute to morbidity and mortality in children with chronic kidney disease (CKD). We evaluated the pharmacokinetics, efficacy, and safety of oral paricalcitol in reducing iPTH levels in children with stages 3-5 CKD. METHODS Children aged 10-16 years with stages 3-5 CKD were enrolled in two phase 3 studies. The stage 3/4 CKD study characterized paricalcitol pharmacokinetics and compared the efficacy and safety of paricalcitol with placebo followed by an open-label period. The stage 5 CKD study evaluated the efficacy and safety of paricalcitol (no comparator) in children with stage 5 CKD undergoing dialysis. RESULTS In the stage 3/4 CKD study, mean peak plasma concentration and area under the time curve from zero to infinity were 0.13 ng/mL and 2.87 ng•h/((or ng×h/))mL, respectively, for 12 children who received 3 μg paricalcitol. Thirty-six children were randomized to paricalcitol or placebo; 27.8% of the paricalcitol group achieved two consecutive iPTH reductions of ≥30% from baseline versus none of the placebo group (P = 0.045). Adverse events were higher in children who received placebo than in those administered paricalcitol during the double-blind treatment (88.9 vs. 38.9%; P = 0.005). In the stage 5 CKD study, eight children (61.5%) had two consecutive iPTH reductions of ≥30% from baseline, and five (38.5%) had two consecutive iPTH values of between 150 and 300 pg/mL. Clinically meaningful hypercalcemia occurred in 21% of children. CONCLUSIONS Oral paricalcitol in children aged 10-16 years with stages 3-5 CKD reduced iPTH levels and the treatment was well tolerated. Results support an initiating dose of 1 μg paricalcitol 3 times weekly in children aged 10-16 years.
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Affiliation(s)
- Nicholas J. A. Webb
- Department of Paediatric Nephrology and NIHR/Wellcome Trust Clinical Research Facility, Manchester Academic Health Science Centre, Royal Manchester Children’s Hospital, University of Manchester, Oxford Road, Manchester, M13 9WL UK
| | - Gary Lerner
- Pediatric Nephrology, Keck School of Medicine–Children’s Hospital Los Angeles, Los Angeles, CA USA
| | - Bradley A. Warady
- Division of Pediatric Nephrology, Children’s Mercy Hospital, Kansas City, MO USA
| | - Katherine M. Dell
- Center for Pediatric Nephrology, Cleveland Clinic Children’s, Case Western Reserve University, Cleveland, OH USA
| | - Larry A. Greenbaum
- Emory School of Medicine and Children’s Healthcare of Atlanta, Atlanta, GA USA
| | - Gema Ariceta
- Pediatric Nephrology, University Hospital Vall d’Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
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8
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Freundlich M, Li YC, Quiroz Y, Bravo Y, Seeherunvong W, Faul C, Weisinger JR, Rodriguez-Iturbe B. Paricalcitol downregulates myocardial renin-angiotensin and fibroblast growth factor expression and attenuates cardiac hypertrophy in uremic rats. Am J Hypertens 2014; 27:720-6. [PMID: 24072555 DOI: 10.1093/ajh/hpt177] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Vitamin D attenuates uremic cardiac hypertrophy, possibly by suppressing the myocardial renin-angiotensin system (RAS) and fibroblast growth factors (FGFs). We compared the suppression of cardiac hypertrophy and myocardial expression of RAS and FGF receptor genes offered by the vitamin D analog paricalcitol (Pc) or the angiotensin-converting enzyme inhibitor enalapril (E) in experimental uremia. METHODS Rats with 5/6 nephrectomy received Pc or E for 8 weeks. Renal function, systolic blood pressure, and cardiac hypertrophy were evaluated. Myocardial expression of RAS genes, brain natriuretic peptide (BNP), and FGF receptor-1 (FGFR-1) were determined using quantitative reverse-transcription (pRT)-PCR. RESULTS Blood pressure, proteinuria, and serum creatinine were significantly higher in untreated uremic animals. Hypertension was significantly reduced by E but only modestly by Pc; however, cardiac hypertrophy in the untreated group was similarly attenuated by Pc or E. Upregulation of myocardial expressions of renin, angiotensinogen, FGFR-1, and BNP in untreated uremic animals was reduced similarly by Pc and E, while the angiotensin II type 1 receptor was downregulated only by E. CONCLUSIONS Uremic cardiac hypertrophy is associated with activation of the myocardial RAS and the FGFR-1. Downregulation of these genes induced by Pc and E results in similar amelioration of left ventricular hypertrophy despite the different antihypertensive effects of these drugs.
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Affiliation(s)
- Michael Freundlich
- Department of Pediatrics, Division of Pediatric Nephrology, University of Miami Miller School of Medicine, Miami, Florida
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9
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Li D, Shao L, Zhou H, Jiang W, Zhang W, Xu Y. The efficacy of cinacalcet combined with conventional therapy on bone and mineral metabolism in dialysis patients with secondary hyperparathyroidism: a meta-analysis. Endocrine 2013; 43:68-77. [PMID: 22669774 DOI: 10.1007/s12020-012-9711-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 05/20/2012] [Indexed: 12/14/2022]
Abstract
Cinacalcet, the first calcimimetic to be approved for the treatment of secondary hyperparathyroidism (SHPT) in the chronic kidney disease patients, offers a novel therapeutic approach to SHPT. The aim of this meta-analysis is to access the efficacy and safety of cinacalcet on bone and mineral metabolism disorders in the dialysis patients with SHPT. Randomized controlled trials on cinacalcet combined with vitamin D and/or phosphate binders in the dialysis patients with SHPT were identified in Pubmed, Sciencedirect, and the Cochrane library. Data were analyzed with RevMan software. We compared the proportion of patients achieving the biochemical targets recommended by the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines and the incidence of adverse events between the cinacalcet and control groups. Six trials involving 2,548 patients were included. A greater proportion of patients in the cinacalcet group compared with the conventional group achieved the KDOQI targets. The relative risks (RRs) were parathyroid hormone (PTH) (RR = 3.51, 95 % CI: 2.38-5.17), calcium (RR = 2.04, 95 % CI: 1.76-2.37), phosphorus (RR = 1.15, 95 % CI: 0.83-1.60), and calcium-phosphorus product (Ca × P) (RR = 1.41, 95 % CI: 1.18-1.69), the number of patients simultaneously achieving the KDOQI targets for PTH + Ca × P was also greater (RR = 3.89, 95 % CI: 2.36-6.41), with p < 0.001 for each. The most common adverse events were nausea, vomiting, diarrhea, and hypocalcemia, which had a higher incidence in the cinacalcet group, but were usually mild to moderate in severity and transient. Compared with conventional therapy, treatment with cinacalcet results in more patients achieving KDOQI targets and offers an effective and safety therapeutic option for controlling mineral and bone disorders in the dialysis patients with SHPT.
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Affiliation(s)
- Dan Li
- Department of Nephrology, The Affiliated Hospital of Qingdao University Medical College, No. 16 Jiangsu Road, The Southern Direct, Qingdao City, Shandong Province, China
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Abstract
Vitamin D deficiency is widespread in both the pediatric and adult chronic kidney disease (CKD) population. CKD is characterized by dysregulation of vitamin D and mineral metabolism. Secondary hyperparathyroidism and its management puts patients with CKD at increased cardiovascular risk. Emergence of experimental and some clinical data suggesting beneficial effects of vitamin D on proteinuria, blood pressure, inflammation and cardiovascular outcomes has pushed it to the center stage of CKD research. Pediatric data on vitamin D dysregulation and its consequences are still in its infancy. Ongoing prospective studies such as Chronic Kidney disease in Children (CKiD) and the Cardiovascular Comorbidity in Children with CKD (4 C) should help to delineate the evolution of disturbances in mineral metabolism and its adverse effects on growth, CKD progression and cardiovascular outcomes.
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11
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Tonbul HZ, Solak Y, Atalay H, Turkmen K, Altintepe L. Efficacy and tolerability of intravenous paricalcitol in calcitriol-resistant hemodialysis patients with secondary hyperparathyroidism: 12-month prospective study. Ren Fail 2012; 34:297-303. [PMID: 22251408 DOI: 10.3109/0886022x.2011.647298] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
RATIONALE/OBJECTIVES Data are limited regarding the use of paricalcitol in calcitriol-resistant patients with secondary hyperparathyroidism (SHPT). We aimed to evaluate the effects of paricalcitol in calcitriol-resistant hemodialysis patients with SHPT. METHODS This is a 12-month, open-label, prospective study. Forty patients with calcitriol-resistant and/or calcitriol-intolerant SHPT were included. After a washout period, all patients converted to paricalcitol with a 1:3 conversion ratio. Serum calcium and phosphorus were monitored monthly, while serum intact parathyroid hormone (iPTH) once in every 3 months. Paricalcitol dose was reduced or discontinued in case of hypercalcemia and/or hyperphosphatemia. Pre- and posttreatment electrolyte and iPTH values were compared with Student's t-test and Wilcoxon signed-rank test, respectively. MAIN FINDINGS Forty patients completed the study. Mean initiation dose of paricalcitol was 23 ± 7 μg/week. Mean serum calcium was 8.9 ± 0.8 mg/dL at baseline and 9.4 ± 0.7 mg/dL at study end (p = 0.07). Mean monthly serum phosphorus levels stayed stable. Paricalcitol was effective in reducing iPTH levels when compared with pretreatment values (747.9 ± 497.2 pg/mL, 307.3 ± 417.1 pg/mL, respectively; p < 0.001). Thirty-two patients had to discontinue intravenous (IV) paricalcitol at some time during their treatment. Main reasons for discontinuation were as follows: hyperphosphatemia (58%), hypercalcemia (25%), and iPTH < 150 pg/mL (17%). PRINCIPLE CONCLUSIONS Paricalcitol was found to be effective in reducing iPTH levels in calcitriol-resistant patients with SHPT despite relatively frequent drug discontinuation rates.
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Affiliation(s)
- Halil Zeki Tonbul
- Division of Nephrology, Department of Internal Medicine, Meram School of Medicine, Selcuk University, Meram, Konya, Turkey
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12
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Schmitt CP, Mehls O. Mineral and bone disorders in children with chronic kidney disease. Nat Rev Nephrol 2011; 7:624-34. [PMID: 21947120 DOI: 10.1038/nrneph.2011.139] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
As children with chronic kidney disease (CKD) have a long lifespan, optimal control of bone and mineral homeostasis is essential not only for the prevention of debilitating skeletal complications and for achieving adequate growth but also for preserving long-term cardiovascular health. As the growing skeleton is highly dynamic and at particular risk of deterioration, close control of bone and mineral homeostasis is required in children with CKD. However, assessment of bone disease is hampered by the limited validity of biochemical parameters-major controversy exists on key issues such as parathyroid hormone target ranges and the lack of useful imaging techniques. The role of newly discovered factors in bone and mineral homeostasis, such as fibroblast growth factor 23, is not yet established. Even though scientific evidence is limited in children with CKD, ergocalciferol or cholecalciferol supplementation and the use of calcium-free phosphate binders is recommended. The new drug cinacalcet is highly promising; however, pediatric experience is still limited to observational data and the effect of cinacalcet on longitudinal growth and pubertal development is unknown. Randomized, controlled trials are underway, including studies of cinacalcet pharmacokinetics and pharmacodynamics in infants.
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Affiliation(s)
- Claus Peter Schmitt
- Division of Pediatric Nephrology, Center for Pediatric and Adolescent Medicine, INF 430, University of Heidelberg, 69120 Heidelberg, Germany.
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No difference between alfacalcidol and paricalcitol in the treatment of secondary hyperparathyroidism in hemodialysis patients: a randomized crossover trial. Kidney Int 2011; 80:841-50. [PMID: 21832979 DOI: 10.1038/ki.2011.226] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Alfacalcidol and paricalcitol are vitamin D analogs used for the treatment of secondary hyperparathyroidism in patients with chronic kidney disease, but have known dose-dependent side effects that cause hypercalcemia and hyperphosphatemia. In this investigator-initiated multicenter randomized clinical trial, we originally intended two crossover study periods with a washout interval in 86 chronic hemodialysis patients. These patients received increasing intravenous doses of either alfacalcidol or paricalcitol for 16 weeks, until parathyroid hormone was adequately suppressed or calcium or phosphate levels reached an upper threshold. Unfortunately, due to a period effect, only the initial 16-week intervention period for 80 patients was statistically analyzed. The proportion of patients achieving a 30% decrease in parathyroid hormone levels over the last four weeks of study was statistically indistinguishable between the two groups. Paricalcitol was more efficient at correcting low than high baseline parathyroid hormone levels, whereas alfacalcidol was equally effective at all levels. There were no differences in the incidence of hypercalcemia and hyperphosphatemia. Thus, alfacalcidol and paricalcitol were equally effective in the suppression of secondary hyperparathyroidism in hemodialysis patients while calcium and phosphorus were kept in the desired range.
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Lima EM, Gesteira MDFC, Bandeira MDFS. Diretrizes do distúrbio do metabolismo mineral e ósseo na doença renal crônica da criança. J Bras Nefrol 2011; 33:232-247. [DOI: 10.1590/s0101-28002011000200021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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VULPIO C, MARESCA G, DISTASIO E, CACACI S, PANOCCHIA N, LUCIANI G, BOSSOLA M. Switch from calcitriol to paricalcitol in secondary hyperparathyroidism of hemodialysis patients: Responsiveness is related to parathyroid gland size. Hemodial Int 2011; 15:69-78. [DOI: 10.1111/j.1542-4758.2010.00514.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Querfeld U, Mak RH. Vitamin D deficiency and toxicity in chronic kidney disease: in search of the therapeutic window. Pediatr Nephrol 2010; 25:2413-30. [PMID: 20567854 DOI: 10.1007/s00467-010-1574-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2009] [Revised: 04/08/2010] [Accepted: 04/09/2010] [Indexed: 01/14/2023]
Abstract
Both vitamin D deficiency and vitamin D toxicity are associated with cardiovascular complications in chronic kidney disease (CKD). Clinical and experiment data indicate that the association of vitamin D levels with cardiovascular disease is best illustrated as a biphasic, or U-shaped, curve. Children and adolescents with CKD need vitamin D due to the demands of a growing skeleton, to prevent renal rickets. However, this therapy carries the risk of severe side effects and chronic toxicity. Observational studies show that vitamin D deficiency and toxicity are frequently present in patients with CKD. In view of the importance of cardiovascular complications for the long-term survival of young patients, these findings demand a judicious use of vitamin D preparations. In clinical practice, the therapeutic window is rather small, presenting a therapeutic challenge to avoid both vitamin D deficiency and toxicity.
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Affiliation(s)
- Uwe Querfeld
- Department of Pediatric Nephrology, Charite Universitaetsmedizin Berlin, Augustenburger Platz 1, Berlin, Germany.
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Treatment of secondary hyperparathyroidism in ESRD: a 2-year, single-center crossover study. Kidney Int 2010:S33-6. [DOI: 10.1038/ki.2010.191] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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New therapies: calcimimetics, phosphate binders and vitamin D receptor activators. Pediatr Nephrol 2010; 25:609-16. [PMID: 20151157 DOI: 10.1007/s00467-010-1462-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2009] [Revised: 12/23/2009] [Accepted: 01/07/2010] [Indexed: 02/08/2023]
Abstract
At present, new compounds are available to treat secondary hyperparathyroidism, namely calcimimetics, novel phosphorus binders and also novel vitamin D receptor activators. Calcimimetics increase the sensitivity of the parathyroid gland to calcium through spatial configurational changes of the calcium-sensing receptor. In addition, experimental studies have demonstrated that calcimimetics also upregulate both the calcium-sensing receptor and the vitamin D receptor. They are efficacious in children, though the experience in paediatric chronic kidney disease is still limited. Sevelamer, lanthanum carbonate and magnesium iron hydroxycarbonate are novel phosphorus binders available on the market. Several studies have demonstrated their efficacy and safety up to 6 years, though costs are the main limitation for a wider use. Since almost all the experience available on the new phosphorus binders comes from its use in adults, studies on children are needed in order to confirm the efficacy and safety of these products. Other new salts and polymers are also being developed. New vitamin D receptor activators, such as paricalcitol, are as effective at suppressing parathyroid hormone (PTH) as the traditional vitamin D receptor activators used for the past two decades, but they have a better and safer profile, showing fewer calcaemic and phosphoraemic effects while preserving the desirable effects of the vitamin D receptor activators on the cardiovascular system, hypertension, inflammation and fibrosis. Their use in children with chronic kidney disease has revealed similar responses to those of adults. The novel compounds discussed in this review should facilitate and improve the management of mineral and bone disorders in children with chronic kidney disease.
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Hijazi R, Abitbol CL, Chandar J, Seeherunvong W, Freundlich M, Zilleruelo G. Twenty-five years of infant dialysis: a single center experience. J Pediatr 2009; 155:111-7. [PMID: 19324367 DOI: 10.1016/j.jpeds.2009.01.007] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2008] [Revised: 11/19/2008] [Accepted: 01/07/2009] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To perform a retrospective analysis of the long-term outcome of infants with end-stage kidney disease (ESKD) treated at our center during the past 25 years. STUDY DESIGN The total cohort (n = 52) was divided into era 1 (1983-1995; n = 23) and era 2 (1996-2008; n = 29). Dialysis morbidity, transplantation, and long-term survival rates were assessed and compared between the 2 eras. RESULTS Average age at initiation of dialysis was 4.4 +/- 5.3 months (range, 0.5-18 months), with 96% begun on peritoneal dialysis. The predominant diagnoses were dysplasia/obstructive uropathy and autosomal recessive polycystic kidney disease. The overall survival rate is 46%, with current age of survivors ranging from 1.5 to 25 years. Mortality rates in the 2 eras were not significantly different. The predominant mortality occurred within the first year. Twenty-four patients received an initial renal transplant at 2.6 +/- 1.7 years of age. Six patients (25%) required a second renal allograft. Increased risk for mortality included African-American ethnicity, oligoanuria, autosomal recessive polycystic kidney disease, and co-morbid diagnoses. CONCLUSIONS Long-term survival is possible in infants with ESKD, although mortality and morbidity remain high. Technical innovations are needed to accommodate smaller infants undergoing dialysis. Early initiation of dialysis treatment is preferable because prognostic indicators remain poorly defined.
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Affiliation(s)
- Rana Hijazi
- Division of Pediatric Nephrology, University of Miami/Holtz Children's Hospital, Miami, FL, USA
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Lee JH. Treatment of chronic kidney disease in children. KOREAN JOURNAL OF PEDIATRICS 2009. [DOI: 10.3345/kjp.2009.52.10.1061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Joo Hoon Lee
- Department of Pediatrics, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
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Freundlich M, Quiroz Y, Zhang Z, Zhang Y, Bravo Y, Weisinger JR, Li YC, Rodriguez-Iturbe B. Suppression of renin–angiotensin gene expression in the kidney by paricalcitol. Kidney Int 2008; 74:1394-402. [DOI: 10.1038/ki.2008.408] [Citation(s) in RCA: 204] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Recent advances in pediatric dialysis: a review of selected articles. Pediatr Nephrol 2008; 23:1737-47. [PMID: 18548287 DOI: 10.1007/s00467-008-0825-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2007] [Revised: 02/29/2008] [Accepted: 03/03/2008] [Indexed: 11/27/2022]
Abstract
Important discoveries and studies that help inform us about the best methods to evaluate and manage children with end-stage renal disease (ESRD) continue to emerge. This review addresses a number of recent publications regarding important clinical issues for children with ESRD. Despite advances made in previous years, many clinical problems remain in the care of the pediatric dialysis patient. This review covers five topics of recent interest: three articles that address important patient outcome measures such as dialysis adequacy and hemoglobin; two articles that address growth failure in a chronic dialysis patients; five articles that address cardiovascular (CV) morbidity, mortality, and interventions to reduce CV risk in children; two articles that address mineral-bone disorder (MBD) and evidence that past strategies for MBD in children may have increased CV disease; and two articles that address nephrogenic systemic fibrosis, a recently described disorder in chronic kidney disease (CKD) patients that occurs in children as well as adults. Using a concise consistent format, each of the 14 key publications is summarized, and the "conclusion" for the practitioner is identified. The goal of this review is to highlight important work done in this area and focus attention on the important issues raised by each article.
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Sanchez CP. Mineral metabolism and bone abnormalities in children with chronic renal failure. Rev Endocr Metab Disord 2008; 9:131-7. [PMID: 18175221 DOI: 10.1007/s11154-007-9071-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2007] [Accepted: 12/14/2007] [Indexed: 10/22/2022]
Abstract
Abnormalities in mineral metabolism and changes in skeletal histology may contribute to growth impairment in children with chronic renal failure. Hyperphosphatemia, hypocalcemia, metabolic acidosis, alterations in vitamin D and IGF synthesis and parathyroid gland dysfunction play significant roles in the development of secondary hyperparathyroidism and subsequently, bone disease in renal failure. The recent KDIGO conference has made recommendations to consider this as a systemic disorder (chronic kidney disease-mineral bone disorder) and to standardize bone histomorphometry to include bone turnover, mineralization and volume (TMV). The use of DXA to assess bone mass is controversial in children with chronic renal failure. Questions arise regarding the accuracy of bone measurements and difficulty in data interpretation especially in children with renal failure who are not only growth retarded but often have pubertal delay and osteosclerosis. The validity and feasibility of new modalities of skeletal imaging which can detect changes in both trabecular and cortical bone are currently being investigated in children. The management of mineral abnormalities and bone disease in chronic renal failure is multifactorial. To manage hyperphosphatemia, dietary phosphate restriction accompanied by intake of calcium-free and metal-free phosphate binding agents are widely utilized. Vitamin D analogs remain the primary therapy for secondary hyperparathyroidism, although the use of the less hypercalcemic agents is preferred due to concerns of calciphylaxis and vascular calcification. Future clinical studies are needed to evaluate the long-term effects of calcimimetic agents and bisphosphonate therapy in children with chronic renal failure.
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Affiliation(s)
- Cheryl P Sanchez
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, 1300 University Avenue, Madison, WI 53706, USA.
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