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Liu X, Liu Y, Zheng P, Xie X, Li Z, Yang R, Jin L, Mei Z, Chen P, Zhou L. Effects of active vitamin D analogs and calcimimetic agents on PTH and bone mineral biomarkers in hemodialysis patients with SHPT: a network meta-analysis. Eur J Clin Pharmacol 2024; 80:1555-1569. [PMID: 39002024 DOI: 10.1007/s00228-024-03730-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 07/06/2024] [Indexed: 07/15/2024]
Abstract
OBJECTIVE Active vitamin D analogs and calcimimetic agents are primary drugs for patients with secondary hyperparathyroidism. Due to the different pharmacological mechanisms, they have different effects on the level of parathyroid hormone, serum calcium, phosphorus, and bone turnover biomarkers. This study aimed to evaluate the active vitamin D analogs and calcimimetic agents in hemodialysis patients with secondary hyperparathyroidism. METHODS We included randomized clinical trials of hemodialysis patients with secondary hyperparathyroidism, comparing active vitamin D analogs to calcimimetic agents or placebo/control. The primary outcome was the change of PTH level from baseline to end-up. The secondary outcome was the change in serum calcium, phosphorus, calcium-phosphorus product, and bone turnover biomarkers. A network meta-analysis method was applied to complete this study. The forest plots reflected statistical differences in the outcomes between active vitamin D analogs and calcimimetic agents. The SUCRA result presented the ranking of impact on the outcomes. RESULTS Twenty-one randomized clinical trials with 4653 patients were included in this network meta-analysis. Global and splitting-node inconsistencies provided no evidence of inconsistency in this study. There was no statistical difference between two active vitamin D analogs and three calcimimetic agents in the PTH, and phosphorus levels changed. Considering serum calcium level, compared with placebo, calcitriol (9.73, 3.09 to 16.38) and paricalcitol (9.74, 3.87 to 15.60) increase serum calcium. However, cinacalcet (- 1.94, - 3.72 to - 0.15) and etelcalcetide (- 7.80, - 11.80 to - 3.80) reduced the serum calcium, even a joint use of cinacalcet with active vitamin D analogs (- 5.83, - 9.73 to - 1.93). Three calcimimetic agents decreased calcium levels much more than calcitriol and paricalcitol. The same type of drugs was not distinct, with each one affecting the change in calcium level. Cinacalcet reduced calcium-phosphorus product much more than paricalcitol (- 3.66, - 6.72 to - 0.60). Evocalcet decreased calcium-phosphorus product more than cinacalcet (- 5.64, - 8.91 to - 2.37), calcitriol (- 9.36, - 14.81 to - 3.92), and paricalcitol (- 9.30, - 13.78 to - 4.82). Compared with paricalcitol, cinacalcet significantly increases the level of ALP (24.50, 23.05 to 25.95) and bALP (0.67, 0.03 to 1.31). The incidence of gastrointestinal disorders in cinacacet (29.35, 1.71 to 504.98) and etelcalcetide (20.92, 1.20 to 365.68) was notably higher than in paricalcitol. Etelcalcetide (0.71, 0.53 to 0.96) and evocalcet (0.46, 0.33 to 0.64) presented a lower rate of gastrointestinal disorders than cinacalcet. Cinacalcet ranked first in adverse gastrointestinal, nervous, and respiratory reactions. CONCLUSION The same kinds of agents perform similar efficacy on the level of PTH, serum calcium, phosphorus, and calcium-phosphorus product. Paricalcitol did not lead to more hypercalcemia than calcitriol. The calcium decrease induced by cinacalcet was not settled even by associating it with active vitamin D analogs. Cinacalcet and evocalcet were superior to calcitriol and paricacitol in reducing calcium-phosphorus product. Calcimimetics induced more gastrointestinal disorders than active vitamin D analogs, especially cinacalcet.
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Affiliation(s)
- Xing Liu
- Jiangxi Medical College, Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Yichen Liu
- Jiangxi Medical College, Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Peimin Zheng
- Jiangxi Medical College, Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Xun Xie
- Jiangxi Medical College, Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Zhouzhou Li
- Jiangxi Medical College, Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Rui Yang
- Jiangxi Medical College, Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Lie Jin
- Lishui Central Hospital, the Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, 323000, Zhejiang, China
| | - Ziwei Mei
- Lishui Central Hospital, the Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, 323000, Zhejiang, China
| | - Peipei Chen
- Lishui Central Hospital, the Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, 323000, Zhejiang, China
| | - Limei Zhou
- Lishui Central Hospital, the Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, 323000, Zhejiang, China.
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Tsai SH, Kan WC, Jhen RN, Chang YM, Kao JL, Lai HY, Liou HH, Shiao CC. Secondary hyperparathyroidism in chronic kidney disease: A narrative review focus on therapeutic strategy. Clin Med (Lond) 2024; 24:100238. [PMID: 39208984 DOI: 10.1016/j.clinme.2024.100238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 08/13/2024] [Accepted: 08/15/2024] [Indexed: 09/04/2024]
Abstract
Chronic kidney disease (CKD) affects over 10% of the global population. One crucial complication of CKD is secondary hyperparathyroidism (SHPT), marked by elevated parathyroid hormone levels due to hyperphosphataemia, hypocalcaemia, and low active vitamin D from impaired renal function. SHPT increases risks of bone deformities, vascular calcification, cardiovascular events and mortality. This review examines SHPT treatment strategies in patients with CKD. First-line treatments include phosphate binders, vitamin D receptor activators and calcimimetics. When these fail, invasive options like parathyroidectomy (PTX) and thermal ablation are considered. PTX effectively reduces symptoms and improves radiological outcomes, outperforming medical treatment alone in reducing cardiovascular risk and mortality. Thermal ablation techniques, such as microwave, radiofrequency, laser or high-intensity focused ultrasound, offer less invasive alternatives with promising results. Future research should explore the molecular mechanisms of parathyroid gland hyperplasia and evaluate various treatments' impacts.
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Affiliation(s)
- Shin-Hwa Tsai
- Department of Internal Medicine, National Taiwan University Hospital, No.7, Zhongshan S. Rd., Zhongzheng Dist., Taipei City, 100225, Taiwan, ROC.
| | - Wei-Chih Kan
- Department of Nephrology, Department of Internal Medicine, Chi Mei Medical Center, No.901, Zhonghua Rd., Yongkang Dist., Tainan City, 71004, Taiwan, ROC; Department of Medical Laboratory Science and Biotechnology, Chung Hwa University of Medical Technology, No.89, Wenhua 1st St., Rende Dist., Tainan City, 71703, Taiwan, ROC.
| | - Rong-Na Jhen
- Division of Nephrology, Department of Internal Medicine, Camillian Saint Mary's Hospital Luodong, No. 160, Zhongzheng S. Rd., Luodong Township, 265, Yilan County, Taiwan, ROC.
| | - Yu-Ming Chang
- Division of Nephrology, Department of Internal Medicine, Camillian Saint Mary's Hospital Luodong, No. 160, Zhongzheng S. Rd., Luodong Township, 265, Yilan County, Taiwan, ROC.
| | - Jsun-Liang Kao
- Division of Nephrology, Department of Internal Medicine, Camillian Saint Mary's Hospital Luodong, No. 160, Zhongzheng S. Rd., Luodong Township, 265, Yilan County, Taiwan, ROC.
| | - Hsien-Yung Lai
- Department of Anesthesiology, Da Chien General. Hospital, No. 36 Gongjing Rd., Miaoli City, Miaoli County, 360012, Taiwan, ROC.
| | - Hung-Hsiang Liou
- Division of Nephrology, Department of Internal Medicine, Hsin-Jen Hospital, No. 387 Chong-Cheng Rd., Xinzhuang District, 242009, New Taipei City, Taiwan, ROC.
| | - Chih-Chung Shiao
- Division of Nephrology, Department of Internal Medicine, Camillian Saint Mary's Hospital Luodong, No. 160, Zhongzheng S. Rd., Luodong Township, 265, Yilan County, Taiwan, ROC.
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3
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He L, Li Y, Jin J, Cheng M, Bai Y, Xu J. Comparative efficacy of sodium thiosulfate, bisphosphonates, and cinacalcet for the treatment of vascular calcification in patients with haemodialysis: a systematic review and network meta-analysis. BMC Nephrol 2024; 25:26. [PMID: 38254024 PMCID: PMC10804723 DOI: 10.1186/s12882-024-03460-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 01/06/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Up to now, there is no unequivocal intervention to mitigate vascular calcification (VC) in patients with hemodialysis. This network meta-analysis aimed to systematically evaluate the clinical efficacy of sodium thiosulfate, bisphosphonates, and cinacalcet in treating vascular calcification. METHODS A comprehensive study search was performed using PubMed, Web of Science, the Cochrane Library, EMBASE and China National Knowledge Internet (CNKI) to collect randomized controlled trials (RCTs) of sodium thiosulfate, bisphosphonates, and cinacalcet for vascular calcification among hemodialysis patients. Then, network meta-analysis was conducted using Stata 17.0 software. RESULTS In total, eleven RCTs including 1083 patients were qualified for this meta-analysis. We found that cinacalcet (SMD - 0.59; 95% CI [-0.95, -0.24]) had significant benefit on vascular calcification compared with conventional therapy, while sodium thiosulfate or bisphosphonates did not show such efficiency. Furthermore, as for ranking the efficacy assessment, cinacalcet possessed the highest surface under the cumulative ranking curve (SUCRA) value (88.5%) of lessening vascular calcification and was superior to sodium thiosulfate (50.4%) and bisphosphonates (55.4%). Thus, above results suggested that cinacalcet might be the most promising drug for vascular calcification treatment in hemodialysis patients. Mechanistically, our findings illustrated that cinacalcet reduced serum calcium (SMD - 1.20; 95% CI [-2.08, - 0.33]) and showed the tendency in maintaining the balance of intact Parathyroid Hormone (iPTH) level. CONCLUSIONS This network meta-analysis indicated that cinacalcet appear to be more effective than sodium thiosulfate and bisphosphonates in mitigating vascular calcification through decreasing serum calcium and iPTH. And cinacalcet might be a reasonable option for hemodialysis patients with VC in clinical practice. SYSTEMATIC REVIEW REGISTRATION [ http://www.crd.york.ac.uk/PROSPERO ], identifier [CRD42022379965].
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Affiliation(s)
- Lei He
- Departments of Nephrology, Hebei Key Laboratory of vascular calcification in kidney disease; Hebei Clinical Research Center for Chronic Kidney Disease, The Fourth Hospital of Hebei Medical University, 12 Jiankang Road, 050011, Shijiazhuang, China
| | - Yuzhe Li
- Departments of Nephrology, Hebei Key Laboratory of vascular calcification in kidney disease; Hebei Clinical Research Center for Chronic Kidney Disease, The Fourth Hospital of Hebei Medical University, 12 Jiankang Road, 050011, Shijiazhuang, China
| | - Jingjing Jin
- Departments of Nephrology, Hebei Key Laboratory of vascular calcification in kidney disease; Hebei Clinical Research Center for Chronic Kidney Disease, The Fourth Hospital of Hebei Medical University, 12 Jiankang Road, 050011, Shijiazhuang, China
| | - Meijuan Cheng
- Departments of Nephrology, Hebei Key Laboratory of vascular calcification in kidney disease; Hebei Clinical Research Center for Chronic Kidney Disease, The Fourth Hospital of Hebei Medical University, 12 Jiankang Road, 050011, Shijiazhuang, China
| | - Yaling Bai
- Departments of Nephrology, Hebei Key Laboratory of vascular calcification in kidney disease; Hebei Clinical Research Center for Chronic Kidney Disease, The Fourth Hospital of Hebei Medical University, 12 Jiankang Road, 050011, Shijiazhuang, China
| | - Jinsheng Xu
- Departments of Nephrology, Hebei Key Laboratory of vascular calcification in kidney disease; Hebei Clinical Research Center for Chronic Kidney Disease, The Fourth Hospital of Hebei Medical University, 12 Jiankang Road, 050011, Shijiazhuang, China.
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Yamada S, Tsuruya K, Kitazono T, Nakano T. Emerging cross-talks between chronic kidney disease-mineral and bone disorder (CKD-MBD) and malnutrition-inflammation complex syndrome (MICS) in patients receiving dialysis. Clin Exp Nephrol 2022; 26:613-629. [PMID: 35353283 PMCID: PMC9203392 DOI: 10.1007/s10157-022-02216-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 03/22/2022] [Indexed: 12/14/2022]
Abstract
Chronic kidney disease–mineral and bone disorder (CKD–MBD) is a systemic disorder that affects multiple organs and systems and increases the risk of morbidity and mortality in patients with CKD, especially those receiving dialysis therapy. CKD–MBD is highly prevalent in CKD patients, and its treatment is gaining attention from healthcare providers who manage these patients. Additional important pathologies often observed in CKD patients are chronic inflammation and malnutrition/protein-energy wasting (PEW). These two pathologies coexist to form a vicious cycle that accelerates the progression of various other pathologies in CKD patients. This concept is integrated into the term “malnutrition–inflammation–atherosclerosis syndrome” or “malnutrition–inflammation complex syndrome (MICS)”. Recent basic and clinical studies have shown that CKD–MBD directly induces inflammation as well as malnutrition/PEW. Indeed, higher circulating levels of inorganic phosphate, fibroblast growth factor 23, parathyroid hormone, and calciprotein particles, as markers for critical components and effectors of CKD–MBD, were shown to directly induce inflammatory responses, thereby leading to malnutrition/PEW, cardiovascular diseases, and clinically relevant complications. In this short review, we discuss the close interplay between CKD–MBD and MICS and emphasize the significance of simultaneous control of these two seemingly distinct pathologies in patients with CKD, especially those receiving dialysis therapy, for better management of the CKD/hemodialysis population.
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Affiliation(s)
- Shunsuke Yamada
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 8128582, Japan.
| | | | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 8128582, Japan
| | - Toshiaki Nakano
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 8128582, Japan
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5
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Liu Y, Yang Q, Chen G, Zhou T. A Systematic Review and Meta-analysis of Efficacy and Safety of Calcimimetic Agents in the Treatment of Secondary Hyperparathyroidism in Patients with Chronic Kidney Disease. Curr Pharm Des 2022; 28:3289-3304. [PMID: 36305135 DOI: 10.2174/1381612829666221027110656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 09/26/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Some reports have pointed out that calcimimetics agents are effective in the treatment of secondary hyperparathyroidism (SHPT) in chronic kidney disease (CKD) patients, but there is no detailed description of the advantages and disadvantages of calcimimetics agents of SHPT in CKD patients. We tried to pool the published data to verify the effectiveness of calcimimetics agents and to compare the advantages and disadvantages of cinacalcet compared with control in the treatment of SHPT in CKD patients. METHODS We included eligible studies of published papers from January 1st, 2000 to December 31st, 2020 in Medline, Pubmed and Web of science databases, and the data were extracted for this meta-analysis. RESULTS Twenty-seven studies were eligible, and all the included studies were randomized controlled trials (RCT) including patients treated with long-term dialysis. The results indicated that calcimimetic agents can reduce the parathyroid hormone (PTH, pg/ml) level (WMD = -178.22, 95% CI: -238.57, -117.86, P < 0.00001), calcium (Ca, mg/dl) level (WMD = -0.71, 95% CI: -0.86, -0.55, P < 0.00001), phosphorus (P, mg/dl) level (WMD = -0.32, 95% CI: -0.55, -0.08, P = 0.008), calcium-phosphorus product level (WMD = -7.73, 95% CI: -9.64, -5.82, P < 0.00001). Calcimimetic agents increased the bone alkaline phosphatase (BSAP, ng/ml) levels and rate of achieving target PTH, and reduced osteocalcin levels and the rate of parathyroidectomy. Calcimimetic agents increased the total adverse events' rate, the rate of hypocalcemia and gastrointestinal side effects (nausea, vomiting, abdominal pain and diarrhea), but there was no significant difference in serious adverse events between the calcimimetic agent group and control group. CONCLUSION Calcimimetic agents can reduce the PTH level, Ca level, P level, calcium-phosphorus product level and do not increase serious adverse events.
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Affiliation(s)
- Yiping Liu
- Department of Nephrology, the Second Affiliated Hospital, Shantou University Medical College, 515041, Shantou, China
| | - Qian Yang
- Department of Nephrology, the Second Affiliated Hospital, Shantou University Medical College, 515041, Shantou, China
| | - Guangyong Chen
- Department of Nephrology, the Second Affiliated Hospital, Shantou University Medical College, 515041, Shantou, China
| | - Tianbiao Zhou
- Department of Nephrology, the Second Affiliated Hospital, Shantou University Medical College, 515041, Shantou, China
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6
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Ureña-Torres P, D'Marco L, Raggi P, García-Moll X, Brandenburg V, Mazzaferro S, Lieber A, Guirado L, Bover J. Valvular heart disease and calcification in CKD: more common than appreciated. Nephrol Dial Transplant 2021; 35:2046-2053. [PMID: 31326992 DOI: 10.1093/ndt/gfz133] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 05/14/2019] [Indexed: 12/12/2022] Open
Abstract
Ischaemic heart disease, sudden cardiac death and arrhythmias, heart failure, stroke and peripheral arterial disease make up >50% of the causes of death in advanced chronic kidney disease (CKD). Calcification of the vascular tree and heart valves is partially related to these complications and has received growing attention in the literature. However, the main focus of research has been on the pathophysiology and consequences of vascular calcification, with less attention being paid to valvular calcification (VC) and its impact on the survival of CKD patients. Although VC has long been seen as an age-related degenerative disorder with minimal functional impact, several studies proved that it carries an increased risk of death and clinical consequences different from those of vascular calcification. In dialysis patients, the annual incidence of aortic valve calcification is nearly 3.3% and the reported prevalence of aortic and mitral VC varies between 25% and 59%. Moreover, calcification of both valves occurs 10-20 years earlier in CKD patients compared with the general population. Therefore, the purpose of this review is to summarize the current knowledge on the pathophysiology and relevance of VC in CKD patients, and to highlight specific clinical consequences and potential therapeutic implications.
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Affiliation(s)
- Pablo Ureña-Torres
- Department of Dialysis, AURA Nord Saint Ouen, Saint Ouen, France.,Department of Renal Physiology, Necker Hospital, University of Paris Descartes, Paris, France
| | - Luis D'Marco
- Fundació Puigvert, Department of Nephrology and Cardiology, IIB Sant Pau, RedinRen, Barcelona, Catalonia, Spain.,Consorci Sanitari del Garraf, Department of Nephrology, Barcelona, Catalonia, Spain
| | - Paolo Raggi
- Department of Medicine-Cardiology, University of Alberta, Edmonton, AB, Canada
| | - Xavier García-Moll
- Fundació Puigvert, Department of Nephrology and Cardiology, IIB Sant Pau, RedinRen, Barcelona, Catalonia, Spain
| | - Vincent Brandenburg
- Department of Cardiology and Intensive Care Medicine, RWTH University Hospital Aachen, Aachen, Germany
| | - Sandro Mazzaferro
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Ari Lieber
- Department of Cardiology, Ramsay-Générale de Santé, Clinique du Landy, Saint Ouen, France
| | - Lluis Guirado
- Fundació Puigvert, Department of Nephrology and Cardiology, IIB Sant Pau, RedinRen, Barcelona, Catalonia, Spain
| | - Jordi Bover
- Fundació Puigvert, Department of Nephrology and Cardiology, IIB Sant Pau, RedinRen, Barcelona, Catalonia, Spain
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7
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Xu W, Gong L, Lu J, Tang W. Paricalcitol vs. cinacalcet for secondary hyperparathyroidism in chronic kidney disease: A meta-analysis. Exp Ther Med 2020; 20:3237-3243. [PMID: 32855693 PMCID: PMC7444362 DOI: 10.3892/etm.2020.9044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 06/17/2020] [Indexed: 11/29/2022] Open
Abstract
Paricalcitol and cinacalcet have been recommended to reduce parathyroid hormone (PTH) levels for patients with secondary hyperparathyroidism (SHPT) and chronic kidney disease (CKD), and they are able to reduce the risk of hypercalcemia and hyperphosphatemia. However, to date, it has remained uncertain which is the better drug. The aim of the present meta-analysis was to evaluate the effects on PTH, calcium and phosphorus metabolism between the two drugs. The PubMed, the Cochrane Library and Embase databases were searched from inception to June 1, 2019 and eligible studies comparing paricalcitol and cinacalcet for SHPT were included. Data were analysed using Review Manager version 5.3. A total of 7 trials from six articles, comprising 456 patients in the paricalcitol group and 412 patients in the cinacalcet group, were included in the meta-analysis. There were no differences in PTH levels [mean difference (MD): 71.82, 95% CI: -185.20-328.85, P=0.58] and phosphorus levels (standard MD: 0.59, 95% CI: -0.82-2.00, P=0.41). The calcium levels in the paricalcitol group were significantly higher than those in the cinacalcet group (MD: 1.10, 95% CI: 0.92-1.28, P<0.05). In conclusion, paricalcitol and cinacalcet exhibited no difference in their efficacy to control of PTH levels, as they were similarly effective in decreasing the PTH levels. They also had comparable efficacy in the management of phosphorus levels. However, cinacalcet produced a significantly greater reduction in serum calcium levels. More large multicentre randomized controlled trials are necessary to confirm the conclusions of the present analysis.
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Affiliation(s)
- Wei Xu
- Department of Nephrology, Wujin Hospital Affiliated to Jiangsu University, Changzhou, Jiangsu 213000, P.R. China.,Department of Nephrology, Wujin Clinical College of Xuzhou Medical University, Changzhou, Jiangsu 213000, P.R. China
| | - Lifeng Gong
- Department of Nephrology, Wujin Hospital Affiliated to Jiangsu University, Changzhou, Jiangsu 213000, P.R. China.,Department of Nephrology, Wujin Clinical College of Xuzhou Medical University, Changzhou, Jiangsu 213000, P.R. China
| | - Jingkui Lu
- Department of Nephrology, Wujin Hospital Affiliated to Jiangsu University, Changzhou, Jiangsu 213000, P.R. China.,Department of Nephrology, Wujin Clinical College of Xuzhou Medical University, Changzhou, Jiangsu 213000, P.R. China
| | - Weigang Tang
- Department of Nephrology, Wujin Hospital Affiliated to Jiangsu University, Changzhou, Jiangsu 213000, P.R. China.,Department of Nephrology, Wujin Clinical College of Xuzhou Medical University, Changzhou, Jiangsu 213000, P.R. China
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8
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Sun Y, Tian B, Sheng Z, Wan P, Xu T, Yao L. Efficacy and safety of cinacalcet compared with other treatments for secondary hyperparathyroidism in patients with chronic kidney disease or end-stage renal disease: a meta-analysis. BMC Nephrol 2020; 21:316. [PMID: 32736534 PMCID: PMC7393724 DOI: 10.1186/s12882-019-1639-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 11/22/2019] [Indexed: 11/12/2022] Open
Abstract
Background It is controversial for the effect and safety between cinacalcet and other treatments in treating secondary hyperparathyroidism for patients with chronic kidney disease (CKD) or end-stage renal disease (ESRD). Methods Embase, PubMed, and Cochrane Library were searched through Feb 2017. 21 randomized controlled trials were included. We calculated the pooled mean difference (MD), relative risk (RR) and corresponding 95% confidence interval (CI). Result Patients received calcimimetic agents had significantly decreased serum parathyroid hormone (MD = − 259.24 pg/mL, 95% CI: − 336.23 to − 182.25), calcium (MD = − 0.92 mg/dL, 95% CI: − 0.98 to − 0.85) and calcium phosphorus product (MD = − 5.97 mg2/dL2, 95% CI: − 9.77 to − 2.16) concentration compared with control treatment. However, the differences in cardiovascular mortality and all-cause mortality between calcimimetics agents and control group were not statistically significant. The incidence of nausea (RR = 2.13, 95% CI: 1.62 to 2.79), vomiting (RR = 1.99, 95% CI: 1.78 to 2.23) and hypocalcemia (RR = 10.10, 95% CI: 7.60 to 13.43) in CKD patients with calcimimetics agents was significantly higher than that with control treatment. Conclusion Cinacalcet improved the biochemical parameters in CKD patients, but did not improve all-cause mortality and cardiovascular mortality. Moreover, cinacalcet can cause some adverse events.
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Affiliation(s)
- Yiting Sun
- Department of Clinical Medicine, China Medical University, Shenyang, 110122, Liaoning, China
| | - Binyao Tian
- Department of Nephrology, the First Hospital of China Medical University, Shenyang, 110001, Liaoning, China
| | - Zitong Sheng
- Department of Nephrology, the First Hospital of China Medical University, Shenyang, 110001, Liaoning, China
| | - Pengzhi Wan
- Department of Nephrology, the First Hospital of China Medical University, Shenyang, 110001, Liaoning, China
| | - Tianhua Xu
- Department of Nephrology, the First Hospital of China Medical University, Shenyang, 110001, Liaoning, China
| | - Li Yao
- Department of Nephrology, the First Hospital of China Medical University, Shenyang, 110001, Liaoning, China.
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Bellasi A, Cozzolino M, Malberti F, Cancarini G, Esposito C, Guastoni CM, Ondei P, Pontoriero G, Teatini U, Vezzoli G, Pasquali M, Messa P, Locatelli F. New scenarios in secondary hyperparathyroidism: etelcalcetide. Position paper of working group on CKD-MBD of the Italian Society of Nephrology. J Nephrol 2019; 33:211-221. [PMID: 31853791 PMCID: PMC7118036 DOI: 10.1007/s40620-019-00677-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 10/27/2019] [Indexed: 12/11/2022]
Abstract
Bone mineral abnormalities (defined as Chronic Kidney Disease Mineral Bone Disorder; CKD-MBD) are prevalent and associated with a substantial risk burden and poor prognosis in CKD population. Several lines of evidence support the notion that a large proportion of patients receiving maintenance dialysis experience a suboptimal biochemical control of CKD-MBD. Although no study has ever demonstrated conclusively that CKD-MBD control is associated with improved survival, an expanding therapeutic armamentarium is available to correct bone mineral abnormalities. In this position paper of Lombardy Nephrologists, a summary of the state of art of CKD-MBD as well as a summary of the unmet clinical needs will be provided. Furthermore, this position paper will focus on the potential and drawbacks of a new injectable calcimimetic, etelcalcetide, a drug available in Italy since few months ago.
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Affiliation(s)
- Antonio Bellasi
- UOC Ricerca, Innovazione, Brand Reputation, ASST-Papa Giovanni XXIII, Bergamo, Italy
| | - Mario Cozzolino
- UOC Nefrologia e Dialisi ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
| | - Fabio Malberti
- Struttura Complessa di Nefrologia e Dialisi, Istituti Ospedalieri di Cremona, Cremona, Italy
| | - Giovanni Cancarini
- U.O.C. Nefrologia e Dipartimento della Cronicità, ASST, Spedali Civili e, Università di Brescia, Brescia, Italy
| | - Ciro Esposito
- Struttura Complessa di Nefrologia e Dialisi, ICS Maugeri SpA SB, Università di Pavia, Pavia, Italy
| | | | - Patrizia Ondei
- USS Emodialisi, Azienda Ospedaliera Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | | | - Ugo Teatini
- UOC Nefrologia e Dialisi. ASST Rhodense, Garbagnate M.se, Italy
| | - Giuseppe Vezzoli
- Unità di Nefrologia e Dialisi, IRCCS Istituto Scientifico San Raffaele, Università Vita Salute San Raffaele, Milan, Italy
| | - Marzia Pasquali
- UOC di Nefrologia-Azienda Ospedaliero-Universitaria Policlinico Umberto I Roma, Rome, Italy
| | - Piergiorgio Messa
- Unità Operativa Complessa di Nefrologia e Dialisi, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
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10
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Louie KS, Erhard C, Wheeler DC, Stenvinkel P, Fouqueray B, Floege J. Cinacalcet-induced hypocalcemia in a cohort of European haemodialysis patients: predictors, therapeutic approaches and outcomes. J Nephrol 2019; 33:803-816. [PMID: 31848883 PMCID: PMC7381480 DOI: 10.1007/s40620-019-00686-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 12/08/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Calcimimetic treatment of secondary hyperparathyroidism in chronic dialysis patients is often followed by hypocalcemia. METHODS We investigated the frequency, predictors, consequences and therapeutic responses following cinacalcet-induced hypocalcemia in an incident European hemodialysis cohort of 1068 patients with a cinacalcet prescription. RESULTS Of 905 normocalcemic patients initiating cinacalcet, 67% developed hypocalcemia within 12 months: 68% mild, 23% moderate, 9% severe. Compared to persistently normocalcemic patients, those with severe hypocalcemia were more often diabetic, overweight, had cardiovascular disease, shorter dialysis vintage, used a catheter dialysis access, had fewer active vitamin-D sterols, and exhibited higher CRP and iPTH and lower calcium levels. Multivariate predictors of hypocalcemia included a catheter for vascular access, low albumin and high iPTH. Generally, no therapeutic intervention to prevent hypocalcemia was taken prior to cinacalcet initiation. After the hypocalcemic event, the most common clinical response was no change of the dialysis or medical regimen. Following the hypocalcemic event, iPTH remained low even in those with severe hypocalcemia. The number of deaths and cardiovascular events did not differ between patients with and without hypocalcemia within six months following cinacalcet initiation. CONCLUSION Two-thirds of cinacalcet initiated patients experienced hypocalcaemia with 9% being severe. Hypocalcemia was mostly asymptomatic, transient (with and without targeted intervention to correct it) and not associated with an increase in cardiovascular events or deaths.
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Affiliation(s)
| | | | - David C Wheeler
- Department of Nephrology, University College London, London UK and George Institute for Global Health, Sydney, Australia
| | - Peter Stenvinkel
- Division of Renal Medicine, Department of Clinical Science Technology and Intervention, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | | | - Jürgen Floege
- Division of Nephrology & Clinical Immunology, RWTH University of Aachen, Pauwelsstraẞe 30, 52057, Aachen, Germany.
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Zu Y, Lu X, Song J, Yu L, Li H, Wang S. Cinacalcet Treatment Significantly Improves All-Cause and Cardiovascular Survival in Dialysis Patients: Results from a Meta-Analysis. Kidney Blood Press Res 2019; 44:1327-1338. [PMID: 31747666 DOI: 10.1159/000504139] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 10/12/2019] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To assess the long-term effects including all-cause mortality, cardiovascular mortality, and fracture incidence, of cinacalcet on secondary hyperparathyroidism (SHPT) in patients on dialysis. METHODS PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched from their inception to October 2018. Randomized controlled trials (RCTs) and cohort design prospective observational studies assessing cinacalcet for the treatment of SHPT in dialysis patients were included. Data extraction was independently completed by 2 authors who determined the methodological quality of the studies and extracted data in duplicate. Study-specific risk estimates were tested by using a fixed effects model. RESULTS A total of 14 articles with 38,219 participants were included, of which 10 RCTs with 7,471 participants and 4 prospective observational studies with 30,748 participants fulfilled the eligibility criteria. Compared with no cinacalcet, cinacalcet administration reduced all-cause mortality (relative risk [RR] 0.91, 95% CI 0.89-0.94, p < 0.001) and cardiovascular mortality (RR 0.92, 95% CI 0.89-0.95, p < 0.001), but it did not significantly reduce the incidence of fractures (RR 0.93, 95% CI 0.87-1.00, p = 0.05). CONCLUSIONS The results of this meta-analysis indicated that the treatment of SHPT with cinacalcet may in fact reduce all-cause mortality and cardiovascular mortality among patients receiving maintenance dialysis.
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Affiliation(s)
- Yuan Zu
- Department of Blood Purification, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xiangxue Lu
- Department of Blood Purification, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jinghong Song
- Department of Blood Purification, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Ling Yu
- Department of Blood Purification, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Han Li
- Department of Blood Purification, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China,
| | - Shixiang Wang
- Department of Blood Purification, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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12
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Cinacalcet plus vitamin D versus vitamin D alone for the treatment of secondary hyperparathyroidism in patients undergoing dialysis: a meta-analysis of randomized controlled trials. Int Urol Nephrol 2019; 51:2027-2036. [PMID: 31531805 DOI: 10.1007/s11255-019-02271-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 08/28/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Secondary hyperparathyroidism (SHPT) is a common and serious complication of chronic kidney disease, particularly in end-stage renal disease. Currently, both cinacalcet and vitamin D are used to treat SHPT via two different mechanisms, but it is still unclear whether the combination use of these two drugs can be a safe and effective alternative to vitamin D alone. Therefore, the aim of this meta-analysis was to assess the efficacy and safety of cinacalcet plus vitamin D in the treatment of SHPT. METHODS Four electronic databases, including PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science, were searched for eligible publications. All randomized-controlled trials comparing cinacalcet plus vitamin D with vitamin D alone in SHPT patients undergoing dialysis were included. Mean difference (MD) with 95% confidence intervals (CIs) and risk ratios (RRs) with 95% CIs were calculated using a random-effects model or fixed-effects model. Sensitivity analysis was conducted by removing any one study successively to estimate the stability of the pooled results, and subgroup analysis was carried out to explore potential sources of heterogeneity, and funnel plots were used to test publication bias. RESULTS A total of 8 randomized-controlled trials involving 1480 patients were included in the study. Compared with vitamin D treatment, the combination use of cinacalcet and vitamin D significantly lowered serum calcium (MD - 0.82, 95% CI - 1.02 to - 0.61, P < 0.001), phosphorus (MD - 0.57, 95% CI - 0.97 to - 0.18, P = 0.005), and calcium × phosphorus product (MD - 9.41, 95% CI - 10.00 to - 8.82, P < 0.001). However, there was no difference in serum parathyroid hormone (PTH, MD 43.99, 95% CI - 49.22 to 137.20, P = 0.35), ≥ 30% reduction in PTH (RR 1.02, 95% CI 0.69-1.52, P = 0.91), and PTH achieve 150-300 pg/ml (RR 0.88, 95% CI 0.68-1.15, P = 0.35). Moreover, the combination therapy did not increase the risk of all adverse events, all-cause mortality, diarrhea, muscle spasms, and headache (all P > 0.05), but had a higher risk of hypocalcemia (RR 17.98, 95% CI 5.68-56.99, P < 0.001), and nausea or vomiting (RR 3.47, 95% CI 2.25-5.35, P < 0.001). CONCLUSIONS In comparison with vitamin D alone, the combination use of cinacalcet and vitamin D significantly lowered serum calcium, phosphorus, and the calcium × phosphorus product, and did not increase the risk of all adverse events, all-cause mortality, diarrhea, muscle spasms, and headache, whereas had no effect on serum PTH and increased the risk of hypocalcemia and nausea or vomiting. Future studies are needed to assess the effects of cinacalcet plus vitamin D on PTH level, cardiovascular events, and other clinical outcomes in larger samples with longer durations.
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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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Kakani E, Elyamny M, Ayach T, El‐Husseini A. Pathogenesis and management of vascular calcification in CKD and dialysis patients. Semin Dial 2019; 32:553-561. [DOI: 10.1111/sdi.12840] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Elijah Kakani
- Division of Hospital Medicine University of Kentucky Lexington KY USA
| | - Mohamed Elyamny
- Division of Nephrology, Bone and Mineral Metabolism University of Kentucky Lexington KY USA
| | - Taha Ayach
- Division of Nephrology, Bone and Mineral Metabolism University of Kentucky Lexington KY USA
| | - Amr El‐Husseini
- Division of Nephrology, Bone and Mineral Metabolism University of Kentucky Lexington KY USA
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15
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Rottembourg J, Menegaux F. Are oxyphil cells responsible for the ineffectiveness of cinacalcet hydrochloride in haemodialysis patients? Clin Kidney J 2019; 12:433-436. [PMID: 31198545 PMCID: PMC6543953 DOI: 10.1093/ckj/sfy062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Indexed: 12/21/2022] Open
Abstract
Parathyroid glands consist primarily of chief cells. In some cases, the proportion of parathyroid oxyphil cells increases in patients with chronic kidney disease. We describe a case of secondary hyperparathyroidism (SHPT) in a patient treated with haemodialysis who initially received large doses of vitamin D and calcium (Ca) supplements, as well as high doses of cinacalcet hydrochloride (C-HCl), but without any effect on parathyroid hormone levels. Following a successful parathyroidectomy, histopathological examination revealed that two of the parathyroid glands consisted of 40% of oxyphil cells. Oxyphil cells have significantly more Ca-sensing receptors (CaSRs) than chief cells, suggesting that CaSRs are involved in the transdifferentiation of chief cells to oxyphil cells. C-HCl treatment leads to a significant increase in parathyroid oxyphil cell content. This case suggests that C-HCl may induce specific phenotypic alterations in hyperplastic parathyroid glands in patients with severe SHPT.
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Affiliation(s)
- Jacques Rottembourg
- Department of Nephrology, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Fabrice Menegaux
- Department of Endocrine Surgery, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
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16
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Rottembourg J, Ureña-Torres P, Toledano D, Gueutin V, Hamani A, Coldefy O, Hebibi H, Guincestre T, Emery C. Factors associated with parathyroid hormone control in haemodialysis patients with secondary hyperparathyroidism treated with cinacalcet in real-world clinical practice: Mimosa study. Clin Kidney J 2019; 12:871-879. [PMID: 31807302 PMCID: PMC6885690 DOI: 10.1093/ckj/sfz021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Indexed: 12/19/2022] Open
Abstract
Background Secondary hyperparathyroidism (SHPT) is frequent in haemodialysis (HD) patients. Oral cinacalcet-hydrochloride (HCl) decreases parathyroid hormone (PTH); however, real-life PTH data, according to Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, are still lacking. Our goal is to assess the percentage of cinacalcet-HCl-treated HD patients with controlled SHPT (PTH <9× upper limit of the normal range) after 12 months (M12) of treatment. Methods This is a retrospective observational study in HD patients with SHPT treated by cinacalcet-HCl between 2005 and 2015 and dialysed in seven French HD centres using the same database (Hemodial™). Results The study included 1268 patients with a mean (standard deviation) follow-up of 21 ± 12 months. Their mean dialysis vintage was 4.3 ± 5.6 years. PTH values were available and exploitable at M12 in 50% of them (645 patients). Among these patients, 58.9% had controlled (mean PTH of 304 ± 158 pg/mL) and 41.1% uncontrolled SHPT (mean PTH of 1084 ± 543) at M12. At the baseline, patients with controlled SHPT were older (66 ± 15 versus 61 ± 17 years), and had lower PTH (831 ± 346 versus 1057 ± 480 pg/mL) and calcaemia (2.18 ± 0.2 versus 2.22 ± 0.19 mmol/L) than uncontrolled patients. In multivariate analysis, these three factors still remained significantly associated with controlled SHPT. Conclusion In this real-life study, 41.1% of HD patients with SHPT treated with cinacalcet-HCl remained with a PTH above the KDIGO recommended target after 12 months of treatment. Apart from the possibility of non-compliance, the severity of SHPT appears to be a major factor determining the response to cinacalcet-HCl treatment, reinforcing the importance of treating SHPT at earlier stages.
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17
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Ye H, Ye P, Zhang Z, Hou A, Liang Z, Kong Y. A Bayesian network analysis on comparative efficacy of treatment strategies for dialysis patients with secondary hyperparathyroidism. Exp Ther Med 2018; 17:531-540. [PMID: 30651833 DOI: 10.3892/etm.2018.6906] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 09/21/2018] [Indexed: 12/16/2022] Open
Abstract
For dialysis patients with end-stage kidney disease and secondary hyperparathyroidism (SHPT), there are three therapeutic treatment options: Cinacalcet, paricalcitol and cinacalcet plus low-dose vitamin D analogues. However, their comparative efficacy remains unclear at present. Thus, in the current study, a Bayesian network analysis was conducted to evaluate the relative efficacy and safety of these three therapeutic regimens. A comprehensive literature database query was performed. The primary outcome was the treatment effect on serum parathyroid hormone (PTH) levels. Secondary outcomes included the occurrence of nausea and hypocalcaemia. A total of 20 randomized clinical trials, including 5,390 dialysis patients, were entered into the analysis. Paricalcitol, cinacalcet plus vitamin D analogue and cinacalcet were significantly more efficacious in controlling PTH levels compared with conventional therapy (which comprises calcium-based phosphate binders, non-calcium-based phosphate binders and vitamin D analogues) [odds ratio (OR)=3.99, 2.91 and 2.47, respectively] and placebo (OR=20.32, 14.89 and 12.56, respectively). Paricalcitol was identified as the most efficacious of the three treatments. According to a ranking analysis, patients treated with cinacalcet had a higher possibility of frequently developing nausea and hypocalcaemia compared with patients treated with cinacalcet plus low-dose active vitamin D analogues. All three therapeutic treatment options were efficacious for the treatment of dialysis patients with SHPT in controlling PTH levels. Paricalcitol had the highest possibility of being the most optimal one. Thus, paricalcitol therapy may be the most optimal regimen in controlling PTH levels, but this should be confirmed by further study.
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Affiliation(s)
- Huizhen Ye
- Nephrology Department, The First People's Hospital of Foshan, Foshan, Guangdong 528000, P.R. China
| | - Peiyi Ye
- Nephrology Department, The First People's Hospital of Foshan, Foshan, Guangdong 528000, P.R. China
| | - Zhe Zhang
- Nephrology Department, The First People's Hospital of Foshan, Foshan, Guangdong 528000, P.R. China
| | - Aizhen Hou
- Nephrology Department, The First People's Hospital of Foshan, Foshan, Guangdong 528000, P.R. China
| | - Zijie Liang
- Nephrology Department, The First People's Hospital of Foshan, Foshan, Guangdong 528000, P.R. China
| | - Yaozhong Kong
- Nephrology Department, The First People's Hospital of Foshan, Foshan, Guangdong 528000, P.R. China
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Beto J, Bhatt N, Gerbeling T, Patel C, Drayer D. Overview of the 2017 KDIGO CKD-MBD Update: Practice Implications for Adult Hemodialysis Patients. J Ren Nutr 2018; 29:2-15. [PMID: 30150095 DOI: 10.1053/j.jrn.2018.05.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 04/06/2018] [Accepted: 05/25/2018] [Indexed: 01/10/2023] Open
Abstract
Renal dietitians play a pivotal role in the ongoing management of chronic kidney disease in patients on hemodialysis. Awareness of changes to clinical practice guidelines that may impact laboratory parameters associated with chronic kidney disease-mineral and bone disorder is important for optimal patient care. In this article, the Kidney Disease: Improving Global Outcomes 2017 Clinical Practice Guideline Update recommendations related to the treatment of secondary hyperparathyroidism in adults on hemodialysis are reviewed and treatment implications for renal dietitians discussed. Specific attention is given to the integration of updated recommendations such as the use of calcimimetics as part of a combination approach to the existing treatment paradigm. Renal dietitians can directly apply the updated clinical recommendations in the evaluation of diet composition; food additives; medication adherence challenges with phosphate binder type and use and serial monitoring of phosphorus, calcium, and parathyroid hormone levels to inform clinical decisions on treatment options for patients.
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Affiliation(s)
- Judith Beto
- Research Associate, Division of Nephrology and Hypertension, Loyola University of Chicago, Maywood, Illinois.
| | - Nisha Bhatt
- US Medical Leader Nephrology, Medical Affairs, Amgen Inc., Thousand Oaks, California
| | - Teresa Gerbeling
- Renal Dietitian Coordinator, Dialysis Center of Lincoln, Lincoln, Nebraska
| | - Chhaya Patel
- Nutrition Program Manager, Divisional Lead RD, ORCA Division, DaVita Inc., Denver, Colorado
| | - Debra Drayer
- Senior Regional Medical Liaison Nephrology, Amgen Inc., Thousand Oaks, California
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19
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Lozano-Ortega G, Waser N, Bensink ME, Goring S, Bennett H, Block GA, Chertow GM, Trotman ML, Cooper K, Levy AR, Belozeroff V. Effects of calcimimetics on long-term outcomes in dialysis patients: literature review and Bayesian meta-analysis. J Comp Eff Res 2018; 7:693-707. [DOI: 10.2217/cer-2018-0015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Aim: Randomized controlled trials (RCTs) with clinical outcomes are considered the gold standard for regulatory approval. However, by design they are only able to answer a small number of clinical questions. Other high-quality studies are required for clinical decision-making. The EVOLVE was the largest RCT, evaluating the effects of cinacalcet on clinical outcomes among adult patients receiving maintenance dialysis suffering from secondary hyperparathyroidism. While the EVOLVE trial did not reach its primary end point, imbalance in subjects’ age at randomization and discontinuation rates are two of the reasons that the lack of mortality benefit is in question. We undertook a systematic literature review and Bayesian meta-analysis combining randomized and observational studies on the estimated effects of the oral calcimimetic cinacalcet on clinical outcomes including all-cause mortality, cardiovascular-related mortality, hospitalization for cardiovascular events, fracture and parathyroidectomy among patients on maintenance dialysis. Methods: Data sources included MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials databases. RCTs and observational studies were included. Data extraction was completed by two authors independently and in duplicate determined the methodological quality of the studies and extracted data. Results: Of 564 unique citations identified, 16 studies were included: six observational studies and ten RCTs. Four high-quality studies (two observational and two RCTs) were deemed suitable for meta-analysis. Results indicated a statistically significant reduction in the risk of death associated with cinacalcet (hazard ratio: 0.83; 95% credible interval: 0.78–0.89).Conclusion: The results of this meta-analysis indicate that treatment of secondary hyperparathyroidism with calcimimetic therapy may in fact reduce mortality among patients receiving maintenance dialysis. This finding provides justification for a well-designed and adequately powered randomized trial to definitively address the question.
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Affiliation(s)
| | | | - Mark E Bensink
- Departments of Global Health Economics (MB, VB), Biostatistics (MLT), and Global Medical (KC), Amgen Inc., One Amgen Center Drive, Thousand Oaks, CA 9132, USA
| | - Sarah Goring
- ICON plc, Epidemiology, Vancouver, BC V6B 1P1, Canada
| | | | - Geoffrey A Block
- Denver Nephrology, 130 Rampart Way, Suite 300b, Denver, CO 80230, USA
| | - Glenn M Chertow
- Stanford University, School of Medicine, 1070 Arastradero Rd, Ste 313, Palo Alto, CA 94034, USA
| | - Marie-Louise Trotman
- Departments of Global Health Economics (MB, VB), Biostatistics (MLT), and Global Medical (KC), Amgen Inc., One Amgen Center Drive, Thousand Oaks, CA 9132, USA
| | - Kerry Cooper
- Departments of Global Health Economics (MB, VB), Biostatistics (MLT), and Global Medical (KC), Amgen Inc., One Amgen Center Drive, Thousand Oaks, CA 9132, USA
| | - Adrian R Levy
- Dalhousie University Department of Community Health and Epidemiology, Halifax, NS B3H 1V7, Canada
| | - Vasily Belozeroff
- Departments of Global Health Economics (MB, VB), Biostatistics (MLT), and Global Medical (KC), Amgen Inc., One Amgen Center Drive, Thousand Oaks, CA 9132, USA
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20
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Incidence, predictors and therapeutic consequences of hypocalcemia in patients treated with cinacalcet in the EVOLVE trial. Kidney Int 2018. [DOI: 10.1016/j.kint.2017.12.014] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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22
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Greeviroj P, Kitrungphaiboon T, Katavetin P, Praditpornsilpa K, Eiam-Ong S, Jaber B, Susantitaphong P. Cinacalcet for Treatment of Chronic Kidney Disease-Mineral and Bone Disorder: A Meta-Analysis of Randomized Controlled Trials. Nephron Clin Pract 2018. [DOI: 10.1159/000487546] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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23
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Cinacalcet versus Placebo for secondary hyperparathyroidism in chronic kidney disease patients: a meta-analysis of randomized controlled trials and trial sequential analysis. Sci Rep 2018; 8:3111. [PMID: 29449603 PMCID: PMC5814442 DOI: 10.1038/s41598-018-21397-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 02/01/2018] [Indexed: 12/31/2022] Open
Abstract
To assess the efficacy and safety of cinacalcet on secondary hyperparathyroidism in patients with chronic kidney disease, Pubmed, Embase, and the Cochrane Central Register of Controlled Trials were searched until March 2016. Trial sequential analysis (TSA) was conducted to control the risks of type I and II errors and calculate required information size (RIS). A total of 25 articles with 8481 participants were included. Compared with controls, cinacalcet administration did not reduce all-cause mortality (RR = 0.97, 95% CI = 0.89–1.05, P = 0.41, TSA-adjusted 95% CI = 0.86–1.08, RIS = 5260, n = 8386) or cardiovascular mortality (RR = 0.95, 95% CI = 0.83–1.07, P = 0.39, TSA-adjusted 95% CI = 0.70–1.26, RIS = 3780 n = 5418), but it reduced the incidence of parathyroidectomy (RR = 0.48, 95% CI = 0.40–0.50, P < 0.001, TSA-adjusted 95% CI = 0.39–0.60, RIS = 5787 n = 5488). Cinacalcet increased the risk of hypocalcemia (RR = 8.48, 95% CI = 6.37–11.29, P < 0.001, TSA-adjusted 95% CI = 5.25–13.70, RIS = 6522, n = 7785), nausea (RR = 2.12, 95% CI = 1.62–2.77, P < 0.001, TSA-adjusted 95% CI = 1.45–3.04, RIS = 4684, n = 7512), vomiting (RR = 2.00, 95% CI = 1.79–2.24, P < 0.001, TSA-adjusted 95% CI = 1.77–2.26, RIS = 1374, n = 7331) and diarrhea (RR = 1.17, 95% CI = 1.05–1.32, P = 0.006, TSA-adjusted 95% CI = 1.02–1.36, RIS = 8388, n = 6116). Cinacalcet did not significantly reduce the incidence of fractures (RR = 0.58, 95% CI = 0.21–1.59, P = 0.29, TSA-adjusted 95% CI = 0.01–35.11, RIS = 76376, n = 4053). Cinacalcet reduced the incidence of parathyroidectomy, however, it did not reduce all-cause and cardiovascular mortality, and increased the risk of adverse events including hypocalcemia and gastrointestinal disorders.
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Inoue H, Shimizu S, Watanabe K, Kamiyama Y, Shima H, Nakase A, Ishida H, Kurita N, Fukuma S, Fukuhara S, Yamada Y. Impact of trajectories of abdominal aortic calcification over 2 years on subsequent mortality: a 10-year longitudinal study. Nephrol Dial Transplant 2017; 33:676-683. [DOI: 10.1093/ndt/gfx253] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 07/06/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Hiroki Inoue
- Department of Radiation Technology, Kitasaito Hospital, Hokkaido, Japan
| | - Sayaka Shimizu
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Institute for Health Outcomes and Process Evaluation Research (iHope International), Kyoto, Japan
| | - Keita Watanabe
- Department of Radiation Technology, Kitasaito Hospital, Hokkaido, Japan
| | - Yasuhiro Kamiyama
- Department of Nursing, Nagayama Kidney Urology Clinic, Hokkaido, Japan
| | - Hitomi Shima
- Office of Health Information Management, Kitasaito Hospital, Hokkaido, Japan
| | - Azuna Nakase
- Office of Health Information Management, Kitasaito Hospital, Hokkaido, Japan
| | | | - Noriaki Kurita
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Institute for Health Outcomes and Process Evaluation Research (iHope International), Kyoto, Japan
- Department of Innovative Research and Education for Clinicians and Trainees (DiRECT), Fukushima Medical University Hospital, Fukushima, Japan
| | - Shingo Fukuma
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Institute for Health Outcomes and Process Evaluation Research (iHope International), Kyoto, Japan
- Center for Innovative Research for Communities and Clinical Excellence (CiRCLE), Fukushima Medical University, Fukushima, Japan
| | - Shunichi Fukuhara
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Institute for Health Outcomes and Process Evaluation Research (iHope International), Kyoto, Japan
- Center for Innovative Research for Communities and Clinical Excellence (CiRCLE), Fukushima Medical University, Fukushima, Japan
| | - Yukari Yamada
- Institute for Health Outcomes and Process Evaluation Research (iHope International), Kyoto, Japan
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KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD). Kidney Int Suppl (2011) 2017; 7:1-59. [PMID: 30675420 PMCID: PMC6340919 DOI: 10.1016/j.kisu.2017.04.001] [Citation(s) in RCA: 1000] [Impact Index Per Article: 142.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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Ohtake T, Kobayashi S. Impact of vascular calcification on cardiovascular mortality in hemodialysis patients: clinical significance, mechanisms and possible strategies for treatment. RENAL REPLACEMENT THERAPY 2017. [DOI: 10.1186/s41100-017-0094-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Pérez-Ricart A, Galicia-Basart M, Alcalde-Rodrigo M, Segarra-Medrano A, Suñé-Negre JM, Montoro-Ronsano JB. Effectiveness of Cinacalcet in Patients with Chronic Kidney Disease and Secondary Hyperparathyroidism Not Receiving Dialysis. PLoS One 2016; 11:e0161527. [PMID: 27588942 PMCID: PMC5010289 DOI: 10.1371/journal.pone.0161527] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 08/08/2016] [Indexed: 12/30/2022] Open
Abstract
Background Secondary hyperparathyroidism (SHPT) is a common complication in chronic kidney disease (CKD) patients. Cinacalcet could be a therapeutic option although its use is controversial in patients not receiving dialysis. Thus, the aim of this study is to assess the effectiveness and safety of cinacalcet in patients with CKD and SHPT without renal replacement treatment (RRT) and without renal transplantation (RT). Methods A retrospective observational study was conducted. Patients were included if they had collected cinacalcet, under off-label use, during 2010 and 2011. Patients selected were followed from the beginning of cinacalcet therapy for one year of treatment. Results A total of 37 patients were included with CKD stage 3 (38%), 4 (51%) and 5 (11%). Baseline mean PTH value was 400.86 ± 168.60 mg/dl. At 12 months, a 67% of patients achieved at least a 30% reduction in their PTH value (p<0.001; CI 49.7–83.6), and the overall mean reduction of PTH values was 38% (p< 0.001; IC -49.1, -27.5). A 28% of the patients achieved KDOQI PTH goals (p = 0.003, CI 12%-50%). At 12 months, mean serum calcium values decreased by 6% and mean serum phosphorus values increased by 13%. A 19% of patients experienced hypocalcemia episodes while an increase of 24% in hyperphosphatemia episodes was observed. A 25% of patients finished cinacalcet before a year of treatment. Main withdrawal reasons were: gastrointestinal and other discomfort (8%), hypocalcaemia (8%), non-compliance (3%), interactions (3%) and excess of efficacy (3%). Conclusions Cinacalcet was effective in patients with CKD and SHPT not receiving dialysis. Electrolytic imbalances could be managed with administration of vitamin D and analogues or phosphate binders.
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Sekercioglu N, Busse JW, Sekercioglu MF, Agarwal A, Shaikh S, Lopes LC, Mustafa RA, Guyatt GH, Thabane L. Cinacalcet versus standard treatment for chronic kidney disease: a systematic review and meta-analysis. Ren Fail 2016; 38:857-74. [DOI: 10.3109/0886022x.2016.1172468] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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Mei C, Chen N, Ding X, Yu X, Wang L, Qian J, Wang M, Jiang G, Li X, Hou F, Zuo L, Wang N, Liu H. Efficacy and safety of Cinacalcet on secondary hyperparathyroidism in Chinese chronic kidney disease patients receiving hemodialysis. Hemodial Int 2016; 20:589-600. [PMID: 26940692 DOI: 10.1111/hdi.12410] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Introduction Secondary hyperparathyroidism (SHPT) develops in patients with chronic renal failure. Cinacalcet hydrochloride has been used successfully in U.S., Europe, and Japan in the treatment of SHPT, while maintaining serum levels of calcium and phosphorus. The efficacy and safety profile of Cinacalcet treatment vs. conventional treatments has been of great interest in clinical practice. In this recent phase III study conducted in China, efficacy and safety of a calcimimetic agent, Cinacalcet (Kyowa Hakko Kirin Co., Ltd.), were assessed for SHPT treatment in stable chronic renal disease patients on hemodialysis. Methods In this double-blind, multicenter, placebo-controlled, randomized phase III study, 238 subjects were enrolled in 12 centers and randomly divided into a Cinacalcet group and a placebo group. The percentage of patients achieving a serum parathyroid hormone (PTH) level ≤250 pg/mL was the primary efficacy end point. Serum calcium and phosphorus levels were measured. Adverse events and serious adverse events were recorded, and causal analysis performed. Findings In primary analysis, 25.4% of the Cinacalcet group and 3.5% of the placebo group achieved the primary end point (PTH ≤250 pg/mL). Calcium and phosphorus levels and calcium-phosphorus product were lower in the Cinacalcet group compared with the placebo group. Eleven serious adverse events were reported and considered to be not related to study drugs. Mild to moderate hypocalcemia and reduced calcium levels were reported and considered to be Cinacalcet related. Discussion This phase III study demonstrated that Cinacalcet is effective and well tolerated in treating SHPT in Chinese chronic kidney disease patients on hemodialysis, and in a patient population with much higher baseline PTH levels.
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Affiliation(s)
| | - Nan Chen
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | | | - Xueqing Yu
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Li Wang
- Sichuan Provincial People's Hospital, Chengdu, China
| | - Jiaqi Qian
- Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mei Wang
- Peking University People's Hospital, Beijing, China
| | - Gengru Jiang
- Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xuemei Li
- Peking Union Medical College Hospital, Beijing, China
| | | | - Li Zuo
- Peking University First Hospital, Beijing, China
| | - Niansong Wang
- The Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hong Liu
- Kyowa Hakko Kirin China Pharmaceutical Co., Ltd, China
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Esteve Simo V, Moreno-Guzmán F, Martínez Calvo G, Fulquet Nicolas M, Pou Potau M, Macias-Toro J, Duarte-Gallego V, Saurina Sole A, Ramírez-de Arellano Serna M. Administración de calcimiméticos posdiálisis: igual efectividad, mejor tolerancia gastrointestinal. Nefrologia 2015; 35:403-9. [DOI: 10.1016/j.nefro.2015.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 12/29/2014] [Indexed: 10/23/2022] Open
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Palmer SC, Teixeira-Pinto A, Saglimbene V, Craig JC, Macaskill P, Tonelli M, de Berardis G, Ruospo M, Strippoli GFM. Association of Drug Effects on Serum Parathyroid Hormone, Phosphorus, and Calcium Levels With Mortality in CKD: A Meta-analysis. Am J Kidney Dis 2015; 66:962-71. [PMID: 26003472 DOI: 10.1053/j.ajkd.2015.03.036] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 03/30/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND Serum parathyroid hormone (PTH), phosphorus, and calcium levels are surrogate outcomes that are central to the evaluation of drug treatments in chronic kidney disease (CKD). This systematic review evaluates the evidence for the correlation between drug effects on biochemical (PTH, phosphorus, and calcium) and all-cause and cardiovascular mortality end points in adults with CKD. STUDY DESIGN Systematic review and meta-analysis. SETTING & POPULATION Adults with CKD. SELECTION CRITERIA FOR STUDIES Randomized trials reporting drug effects on biochemical and mortality end points. INTERVENTION Drug interventions with effects on serum PTH, phosphorus, and calcium levels, including vitamin D compounds, phosphate binders, cinacalcet, bisphosphonates, and calcitonin. OUTCOMES Correlation between drug effects on biochemical and all-cause and cardiovascular mortality. RESULTS 28 studies (6,999 participants) reported both biochemical and mortality outcomes and were eligible for analysis. Associations between drug effects on surrogate biochemical end points and corresponding effects on mortality were weak and imprecise. All correlation coefficients were less than 0.70, and 95% credible intervals were generally wide and overlapped with zero, consistent with the possibility of no association. The exception was an inverse correlation between drug effects on serum PTH levels and all-cause mortality, which was nominally significant (-0.64; 95% credible interval, -0.85 to -0.15), but the strength of this association was very imprecise. Risk of bias within available trials was generally high, further reducing confidence in the summary correlations. Findings were robust to adjustment for age, baseline serum PTH level, allocation concealment, CKD stage, and drug class. LIMITATIONS Low power in analyses and combining evidence from many different drug comparisons with incomplete data across studies. CONCLUSIONS Drug effects on serum PTH, phosphorus, and calcium levels are weakly and imprecisely correlated with all-cause and cardiovascular death in the setting of CKD. Risks of mortality (patient-level outcome) cannot be inferred from treatment-induced changes in biochemical outcomes in people with CKD. Similarly, existing data do not exclude a mortality benefit with treatment. Trials need to address patient-centered outcomes to evaluate drug effectiveness in this setting.
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Affiliation(s)
- Suetonia C Palmer
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | | | | | - Jonathan C Craig
- Sydney School of Public Health, University of Sydney, NSW, Australia
| | - Petra Macaskill
- Sydney School of Public Health, University of Sydney, NSW, Australia
| | - Marcello Tonelli
- Cumming School of Medicine, University of Calgary, Calgary, Canada
| | | | - Marinella Ruospo
- Diaverum Medical Scientific Office and Diaverum Academy, Lund, Sweden; Department of Translational Medicine, Division of Nephrology and Transplantation, Amedeo Avogadro University of Eastern Piedmont, Novara
| | - Giovanni F M Strippoli
- Sydney School of Public Health, University of Sydney, NSW, Australia; Diaverum Medical Scientific Office and Diaverum Academy, Lund, Sweden; Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy.
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Wetmore JB, Gurevich K, Sprague S, Da Roza G, Buerkert J, Reiner M, Goodman W, Cooper K. A Randomized Trial of Cinacalcet versus Vitamin D Analogs as Monotherapy in Secondary Hyperparathyroidism (PARADIGM). Clin J Am Soc Nephrol 2015; 10:1031-40. [PMID: 25904755 DOI: 10.2215/cjn.07050714] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 03/31/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Direct comparison of cinacalcet and vitamin D analogs as monotherapies to lower parathyroid hormone (PTH) levels has not been undertaken. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This was a prospective, multicenter, phase 4, randomized, open-label study that enrolled participants from 2010 to 2012. Adult participants (n=312) on hemodialysis with PTH >450 pg/ml were randomized 1:1 to 12 months of treatment with either cinacalcet (n=155) or vitamin D analogs (n=157) to evaluate the mean percentage change in plasma PTH level (primary end point) and the proportion of participants achieving plasma PTH <300 pg/ml or a ≥30% decrease in PTH (secondary end points). A preplanned analysis to determine whether there were important region-by-treatment interactions was also undertaken. RESULTS Baseline mean PTH was 846 pg/ml (n=155) for cinacalcet and 816 pg/ml (n=157) for vitamin D analog therapy. The mean (95% confidence interval) percentage change from baseline in PTH was -12.1% (-20.0% to -4.1%) in the cinacalcet arm and -7.0% (-14.9% to 0.8%) in the vitamin D analog arm, a difference of -5.0% (-15.4% to 5.4%) (P=0.35). Similarly, there was no difference in achievement of secondary efficacy end points between arms (19.4% and 15.3% of participants with PTH≤300 pg/ml and 42.6% and 33.8% of participants had a PTH reduction >30% in the cinacalcet and vitamin D analog arms, respectively). A prespecified analysis revealed a large treatment-by-region interaction, with nominally greater response to cinacalcet compared with vitamin D analogs in non-United States participants (US versus non-US participants, P<0.001). Hypocalcemia was more common in the cinacalcet arm, whereas hypercalcemia and hyperphosphatemia occurred more often in the vitamin D analog arm. CONCLUSIONS Participants had similar modest reductions in PTH with either cinacalcet or vitamin D analog monotherapy over 52 weeks of treatment, but effects varied by region. Treatments differed with regard to effect on calcium and phosphorus levels.
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Affiliation(s)
- James B Wetmore
- Division of Nephrology, Hennepin County Medical Center, Minneapolis, Minnesota;
| | | | - Stuart Sprague
- Division of Nephrology and Hypertension, NorthShore University HealthSystem, Evanston, Illinois
| | - Gerald Da Roza
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - John Buerkert
- Columbia Nephrology Associates, Columbia, South Carolina; and
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Rodríguez M, Goodman WG, Liakopoulos V, Messa P, Wiecek A, Cunningham J. The Use of Calcimimetics for the Treatment of Secondary Hyperparathyroidism: A 10 Year Evidence Review. Semin Dial 2015; 28:497-507. [DOI: 10.1111/sdi.12357] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Mariano Rodríguez
- Servicio de Nefrologia; IMIBIC; Hospital Universitario Reina Sofia; Córdoba Spain
| | | | - Vassilios Liakopoulos
- Division of Nephrology and Hypertension; 1st Department of Internal Medicine; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Piergiorgio Messa
- Division of Nephrology and Dialysis; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Università di Milano; Milan Italy
| | - Andrzej Wiecek
- Department of Nephrology, Endocrinology and Metabolic Diseases; Medical University of Silesia; Katowice Poland
| | - John Cunningham
- Centre for Nephrology; UCL Medical School; Royal Free Campus; London United Kingdom
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Bone histomorphometry before and after long-term treatment with cinacalcet in dialysis patients with secondary hyperparathyroidism. Kidney Int 2014; 87:846-56. [PMID: 25337774 PMCID: PMC4382689 DOI: 10.1038/ki.2014.349] [Citation(s) in RCA: 128] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 08/20/2014] [Accepted: 08/21/2014] [Indexed: 01/01/2023]
Abstract
The multicenter, single-arm BONAFIDE study characterized the skeletal response to cinacalcet in adult dialysis patients with plasma parathyroid hormone (PTH) levels of 300 pg/ml or more, serum calcium of 8.4 mg/dl or more, bone-specific alkaline phosphatase over 20.9 ng/ml and biopsy-proven high-turnover bone disease. Of 110 enrolled patients, 77 underwent a second bone biopsy with quantitative histomorphometry after 6-12 months of cinacalcet treatment. The median PTH decreased from 985 pg/ml at baseline to 480 pg/ml at the end of study (weeks 44-52). Bone formation rate/tissue area decreased from 728 to 336 μm(2)/mm(2)/day, osteoblast perimeter/osteoid perimeter decreased from 17.4 to 13.9%, and eroded perimeter/bone perimeter decreased from 12.7 to 8.3%. The number of patients with normal bone histology increased from none at baseline to 20 at 12 months. Two patients had adynamic bone at the end of study with a PTH under 150 pg/ml, and one patient with overt hypophosphatemia at baseline that reoccurred during follow-up developed osteomalacia. Thus, long-term treatment with cinacalcet substantially reduced PTH, diminished the elevated bone formation rate/tissue area, lowered several biochemical markers of high-turnover bone disease toward normal, and generally improved bone histology. Twenty patients had normal bone histology at follow-up, whereas most had mild hyperparathyroidism or mixed uremic osteodystrophy.
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Vo TM, Disthabanchong S. Are there ways to attenuate arterial calcification and improve cardiovascular outcomes in chronic kidney disease? World J Cardiol 2014; 6:216-226. [PMID: 24944752 PMCID: PMC4062121 DOI: 10.4330/wjc.v6.i5.216] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Revised: 04/18/2014] [Accepted: 04/19/2014] [Indexed: 02/06/2023] Open
Abstract
The risk of cardiovascular mortality among patients with end-stage renal disease is several times higher than general population. Arterial calcification, a marker of atherosclerosis and a predictor of cardiovascular mortality, is common in chronic kidney disease (CKD). The presence of traditional cardiovascular risk factors such as diabetes, hypertension, hyperlipidemia, and advanced age cannot fully explain the high prevalence of atherosclerosis and arterial calcification. Other factors specific to CKD such as hyperphosphatemia, excess of calcium, high dose active vitamin D and prolonged dialysis vintage play important roles in the development of arterial calcification. Due to the significant health risk, it is prudent to attempt to lower arterial calcification burden in CKD. Treatment of hyperlipidemia with statin has failed to lower atherosclerotic and arterial calcification burden. Data on diabetes and blood pressure controls as well as smoking cessation on cardiovascular outcomes in CKD population are limited. Currently available treatment options include non-calcium containing phosphate binders, low dose active vitamin D, calcimimetic agent and perhaps bisphosphonates, vitamin K and sodium thiosulfate. Preliminary data on bisphosphonates, vitamin K and sodium thiosulfate are encouraging but larger studies on efficacy and outcomes are needed.
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Delanaye P, Krzesinski JM, Cavalier E. EVOLVE : entre déception et optimisme. Nephrol Ther 2013; 9:241-5. [DOI: 10.1016/j.nephro.2013.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Revised: 03/20/2013] [Accepted: 04/06/2013] [Indexed: 11/15/2022]
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