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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 2024:10.1007/s00228-024-03730-5. [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] [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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Shigematsu T, Koiwa F, Isaka Y, Fukagawa M, Hagita K, Watanabe YS, Honda D, Akizawa T. Efficacy and Safety of Upacicalcet in Hemodialysis Patients with Secondary Hyperparathyroidism: A Randomized Placebo-Controlled Trial. Clin J Am Soc Nephrol 2023; 18:1300-1309. [PMID: 37696667 PMCID: PMC10578632 DOI: 10.2215/cjn.0000000000000253] [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: 12/02/2022] [Accepted: 07/27/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Secondary hyperparathyroidism is a major complication of patients undergoing hemodialysis (HD). Upacicalcet, a new injectable calcimimetic, acts on calcium-sensing receptors to suppress parathyroid hormone (PTH) secretion. We examined the efficacy and safety of upacicalcet in patients with secondary hyperparathyroidism receiving HD. METHODS In this phase 3, double-blind, placebo-controlled study, we randomized Japanese patients undergoing HD with serum intact PTH (iPTH) concentrations >240 pg/ml and corrected calcium concentrations ≥8.4 mg/dl. Either upacicalcet or placebo was administered after each HD session for 24 weeks. The primary outcome was the percentage of participants achieving the target mean serum iPTH concentration (60-240 pg/ml) at weeks 22-24. RESULTS A total of 103 participants received upacicalcet, and 50 participants received the placebo. The percentage of participants achieving mean serum iPTH concentrations of 60-240 pg/ml during the evaluation period was 67% (69/103) in the upacicalcet group and 8% (4/50) in the placebo group. The difference between the two groups was 59% (95% confidence interval, 48% to 71%). Upacicalcet also decreased serum fibroblast growth factor-23, bone-specific alkaline phosphatase, total type 1 procollagen-N-propeptide, and tartrate-resistant acid phosphatase-5b concentrations. Adverse events were reported in 85% (88/103) and 72% (36/50) participants in the upacicalcet and placebo groups, respectively. The incidence of upper gastrointestinal adverse events, such as nausea and vomiting, was similar between the two groups. Serum corrected calcium concentrations <7.5 mg/dl were observed in 2% of participants in the upacicalcet group and no participants in the placebo group. CONCLUSIONS Upacicalcet, a novel injectable calcimimetic, is effective and safe for secondary hyperparathyroidism patients receiving HD. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Phase 3 Study of SK-1403, NCT03801980 .
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Affiliation(s)
| | - Fumihiko Koiwa
- Division of Nephrology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Yoshitaka Isaka
- Department of Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology, and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Keiko Hagita
- Clinical Development Department, Sanwa Kagaku Kenkyusho Co., Ltd., Nagoya, Japan
| | - Yukihisa S. Watanabe
- Clinical Development Department, Sanwa Kagaku Kenkyusho Co., Ltd., Nagoya, Japan
| | - Daisuke Honda
- Project Management Department, Sanwa Kagaku Kenkyusho Co., Ltd., Nagoya, Japan
| | - Tadao Akizawa
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
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Morosetti M, Jankovic L, Zappalà L, Agafonova E, Pryshlyak I. Long-term use of etelcalcetide for the treatment of secondary hyperparathyroidism in patients undergoing hemodialysis for end-stage renal failure: a real-life retrospective observational study. Int Urol Nephrol 2023:10.1007/s11255-023-03505-4. [PMID: 36790677 DOI: 10.1007/s11255-023-03505-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 02/01/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Patients with end-stage renal failure (ESRD) or dialysis frequently suffer from secondary hyperparathyroidism (sHPTH), a severe complication of mineral metabolism disorders. The calcimimetic etelcalcetide has been approved and shown efficacy in randomized controlled trials, however, data are limited from real-life studies. This study aimed to evaluate the long-term use etelcalcetide for the treatment of sHPTH (PTH > 600 pg/mL) in patients undergoing extracorporeal hemodialysis for ESRD for at least 2 years. METHODS In 45 patients, we administered etelcalcetide for the treatment of sHPTH (PTH > 600 pg/mL); One group of patients (control group, Group A; N = 26) were previously treated with intravenous vitamin D analogues only (paricalcitol 5 µg/ml, three times/week) and then treated with etelcalcetide and a second group of patients already on cinacalcet therapy for at least six months in combination with iv paricalcitol were switched to etelcalcetide (Group B, N = 19). RESULTS PTH levels decreased over time in both groups of patients, with higher values for patients previously treated with cinacalcet (Group B) compared to Group A for the entire study duration even if the final value of the two groups was comparable. After 12 months, the percentage of subjects who had PTH concentrations within the targets recommended by KDIGO guidelines was 87% in Group A and 58% in Group B. In seven patients, despite a parathyroid gland volume > 1000 mm3, an adequate response in the reduction of PTH was obtained. CONCLUSION Findings from this study demonstrate that the efficacy of etelcalcetide is maintained over the long term.
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Affiliation(s)
- Massimo Morosetti
- Nefrologia e Dialisi, Ospedale GB Grassi, Asl Roma 3, Via Giancarlo Passeroni 28, 00122, Rome, Italy.
| | - Ljiljana Jankovic
- Nefrologia e Dialisi, Ospedale GB Grassi, Asl Roma 3, Via Giancarlo Passeroni 28, 00122, Rome, Italy
| | - Laura Zappalà
- Nefrologia e Dialisi, Ospedale GB Grassi, Asl Roma 3, Via Giancarlo Passeroni 28, 00122, Rome, Italy
| | - Elena Agafonova
- Nefrologia e Dialisi, Ospedale GB Grassi, Asl Roma 3, Via Giancarlo Passeroni 28, 00122, Rome, Italy
| | - Iryna Pryshlyak
- Nefrologia e Dialisi, Ospedale GB Grassi, Asl Roma 3, Via Giancarlo Passeroni 28, 00122, Rome, Italy
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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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Zhang LX, Zhang B, Liu XY, Wang ZM, Qi P, Zhang TY, Zhang Q. Advances in the treatment of secondary and tertiary hyperparathyroidism. Front Endocrinol (Lausanne) 2022; 13:1059828. [PMID: 36561571 PMCID: PMC9763452 DOI: 10.3389/fendo.2022.1059828] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 11/23/2022] [Indexed: 12/12/2022] Open
Abstract
Secondary hyperparathyroidism (SHPT) and tertiary hyperparathyroidism (THPT) are common and complicated clinical endocrine diseases. The parathyroid glands maintain endocrine homeostasis by secreting parathyroid hormone to regulate blood calcium levels. However, structural alterations to multiple organs and systems occur throughout the body due to hyperactivity disorder in SHPT and THPT. This not only decreases the patients' quality of life, but also affects mortality. Since current treatments for these diseases remains unclear, we aimed to develop a comprehensive review of advances in the treatment of SHPT and THPT according to the latest relevant researches.
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Affiliation(s)
- Li-Xi Zhang
- Thyroid Surgery Department, General Surgery Center, First Hospital of Jilin University, Changchun, China
| | - Ben Zhang
- Thyroid Surgery Department, General Surgery Center, First Hospital of Jilin University, Changchun, China
| | - Xu-Yao Liu
- Thyroid Surgery Department, General Surgery Center, First Hospital of Jilin University, Changchun, China
| | - Zi-Ming Wang
- Thyroid Surgery Department, General Surgery Center, First Hospital of Jilin University, Changchun, China
| | - Peng Qi
- Thyroid Surgery Department, General Surgery Center, First Hospital of Jilin University, Changchun, China
| | - Tong-Yue Zhang
- Thyroid Surgery Department, General Surgery Center, First Hospital of Jilin University, Changchun, China
| | - Qiang Zhang
- Thyroid Surgery Department, General Surgery Center, First Hospital of Jilin University, Changchun, China
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Fujioka A, Imanishi Y, Kobayashi I, Hirakawa T, Inoue A, Harada K, Taguchi M, Sugiura Y, Yamada H, Miyaoka D, Hayashi N, Emoto M, Inaba M. Effect of etelcalcetide on parathyroid hormone secretion by primary hyperparathyroidism patient-derived primary parathyroid cells. J Bone Miner Metab 2021; 39:396-403. [PMID: 33047189 DOI: 10.1007/s00774-020-01158-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 09/17/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Etelcalcetide (Parsabiv®, AMG 416/ONO-5163) is a novel allosteric modulator for the calcium-sensing receptor approved for hemodialysis patients with secondary hyperparathyroidism of uremia. Etelcalcetide reduced parathyroid hormone levels in hemodialysis patients with secondary hyperparathyroidism of uremia in clinical studies. However, its direct effect on parathyroid hormone secretion in human parathyroid cells remains unknown. This study aimed to determine if etelcalcetide suppresses parathyroid hormone secretion by human parathyroid cells in vitro. MATERIALS AND METHODS We prepared primary cell cultures from human parathyroid tissue and determined calcium-sensing receptor expression levels by immunohistochemistry. Pathyroid tumors were removed from fourteen patients with primary hyperparathyrodism. Parathyroid tissue was dispersed with collagenase, resuspended in culture medium, incubated for 2 h with etelcalcetide and Ca2+, and the medium was then collected. Final etelcalcetide concentrations in the medium were 0.005-50 µmol/L. Levels of human parathyroid hormone in the medium were determined by enzyme-linked immunosorbent assay. RESULTS In eight of the fourteen parathyroid cell cultures, extracellular Ca2+ reduced parathyroid hormone levels. In four of the eight parathyroid cell cultures which responded extracellular Ca2+, etelcalcetide reduced hormone secretion with the 50% effective concentrations of 0.57, 20.8, 0.42, and 0.57 µmol/L. Expression levels of the calcium-sensing receptor were significantly lower in primary hyperparathyroidism patient-derived parathyroid tissues compared with controls. CONCLUSION This is the first report that etelcalcetide directly reduced parathyroid hormone secretion from the primary cultured human parathyroid cells from patients with primary hyperparathyroidism. To verify this conclusion, further studies are needed using secondary hyperparathyroidism patient-derived parathyroid cells.
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Affiliation(s)
- Aiko Fujioka
- Discovery Research Laboratories, Ono Pharmaceutical Co., Ltd., 3-1-1 Sakurai, Shimamoto-cho, Mishima-gun, Osaka, 618-8585, Japan.
| | - Yasuo Imanishi
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Ikue Kobayashi
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Tomoe Hirakawa
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Atsuto Inoue
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
- Research Promotion, Research Project Management Division, Ono Pharmaceutical Co., Ltd., 3-1-1 Sakurai, Shimamoto-cho, Mishima-gun, Osaka, 618-8585, Japan
| | - Kazutsune Harada
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
- EU/US Drug Development Division, Ono Pharma UK Ltd., MidCity Place, 71 High Holborn, London, WC1V 6EA, UK
| | - Mikiyasu Taguchi
- Discovery Research Laboratories, Ono Pharmaceutical Co., Ltd., 3-1-1 Sakurai, Shimamoto-cho, Mishima-gun, Osaka, 618-8585, Japan
| | - Yoshihiro Sugiura
- Discovery Research Laboratories, Ono Pharmaceutical Co., Ltd., 3-1-1 Sakurai, Shimamoto-cho, Mishima-gun, Osaka, 618-8585, Japan
| | - Hiroyuki Yamada
- Discovery Research Laboratories, Ono Pharmaceutical Co., Ltd., 3-1-1 Sakurai, Shimamoto-cho, Mishima-gun, Osaka, 618-8585, Japan
| | - Daichi Miyaoka
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Noriyuki Hayashi
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Masanori Emoto
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Masaaki Inaba
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
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Takkavatakarn K, Wuttiputhanun T, Phannajit J, Praditpornsilpa K, Eiam-Ong S, Susantitaphong P. Effectiveness of fibroblast growth factor 23 lowering modalities in chronic kidney disease: a systematic review and meta-analysis. Int Urol Nephrol 2021; 54:309-321. [PMID: 33797709 DOI: 10.1007/s11255-021-02848-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 03/25/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The heightened fibroblast growth factor 23 (FGF23) level in patients with chronic kidney disease (CKD) is associated with increased cardiovascular disease and mortality. We performed a systematic review and meta-analysis to synthesize the available strategies to reduce FGF23 in CKD patients. METHODS We conducted a meta-analysis by searching the databases of MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials for randomized controlled trials (RCTs) and single-arm studies that examined the effects of dietary phosphate restriction, phosphate binders, iron supplements, calcimimetics, parathyroidectomy, dialysis techniques, and the outcome of preservation of residual renal function (RRF) on FGF23 levels in CKD patients. Random-effects model meta-analyses were used to compute changes in the outcome of interests. RESULTS A total of 41 articles (7590 patients), comprising 36 RCTs, 5 prospective studies were included in this meta-analysis. Dietary phosphate restriction less than 800 mg per day yielded insignificant effect on FGF23 reduction. Interestingly sevelamer, lanthanum, iron-based phosphate binders, and iron supplement significantly lowered FGF23 levels. In CKD patients with secondary hyperparathyroidism, calcimimetics prescription could significantly reduce FGF23 levels, while surgical parathyroidectomy had no significant effect. In dialysis patients, preservation of RRF and hemoperfusion as well as hemodiafiltration provided a significant decrease in FGF23 levels. CONCLUSIONS The present meta-analysis demonstrated that non-calcium-based phosphate binders including sevelamer, lanthanum, and iron-based phosphate binders, iron supplements, calcimimetics, hemoperfusion, and preservation of RRF could effectively reduce FGF23 in CKD patients.
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Affiliation(s)
- Kullaya Takkavatakarn
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, 1873 RAMA IV, Bangkok, 10330, Thailand
| | - Thunyatorn Wuttiputhanun
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, 1873 RAMA IV, Bangkok, 10330, Thailand
| | - Jeerath Phannajit
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, 1873 RAMA IV, Bangkok, 10330, Thailand
| | - Kearkiat Praditpornsilpa
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, 1873 RAMA IV, Bangkok, 10330, Thailand
| | - Somchai Eiam-Ong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, 1873 RAMA IV, Bangkok, 10330, Thailand
| | - Paweena Susantitaphong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, 1873 RAMA IV, Bangkok, 10330, Thailand.
- Research Unit for Metabolic Bone Disease in CKD Patients, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
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Piccoli GB, Trabace T, Chatrenet A, Carranza de La Torre CA, Gendrot L, Nielsen L, Fois A, Santagati G, Saulnier P, Panocchia N. New Intravenous Calcimimetic Agents: New Options, New Problems. An Example on How Clinical, Economical and Ethical Considerations Affect Choice of Treatment. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E1238. [PMID: 32075103 PMCID: PMC7068561 DOI: 10.3390/ijerph17041238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 02/10/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Dialysis treatment is improving, but several long-term problems remain unsolved, including metabolic bone disease linked to chronic kidney disease (CKD-MBD). The availability of new, efficacious but expensive drugs (intravenous calcimimetic agents) poses ethical problems, especially in the setting of budget limitations. METHODS Reasons of choice, side effects, biochemical trends were discussed in a cohort of 15 patients (13% of the dialysis population) who stared treatment with intravenous calcimimetics in a single center. All patients had previously been treated with oral calcimimetic agents; dialysis efficacy was at target in 14/15; hemodiafiltration was employed in 10/15. Median Charlson Comorbidity Index was 8. The indications were discussed according to the principlist ethics (beneficience, non maleficience, justice and autonomy). Biochemical results were analyzed to support the clinical-ethical choices. RESULTS In the context of a strict clinical and biochemical surveillance, the lack of side effects ensured "non-maleficence"; efficacy was at least similar to oral calcimimetic agents, but tolerance was better. Autonomy was respected through a shared decision-making model; all patients appreciated the reduction of the drug burden, and most acknowledged better control of their biochemical data. The ethical conflict resides in the balance between the clinical "beneficience, non-maleficience" advantage and "justice" (economic impact of treatment, potentially in attrition with other resources, since the drug is expensive and included in the dialysis bundle). The dilemma is more relevant when a patient's life expectancy is short (economic impact without clear clinical advantages), or when non-compliance is an issue (unclear advantage if the whole treatment is not correctly taken). CONCLUSIONS In a context of person-centered medicine, autonomy, beneficence and non-maleficence should weight more than economic justice. While ethical discussions are not aimed at finding "the right answer" but asking "the right questions", this example can raise awareness of the importance of including an ethical analysis in the choice of "economically relevant" drugs.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, University of Torino, 10124 Torino, Italy
- Nephrologie, Centre Hospitalier Le Mans, 72037 Le Mans, France; (T.T.); (A.C.); (C.A.C.d.L.T.); (L.G.); (L.N.); (A.F.); (G.S.)
| | - Tiziana Trabace
- Nephrologie, Centre Hospitalier Le Mans, 72037 Le Mans, France; (T.T.); (A.C.); (C.A.C.d.L.T.); (L.G.); (L.N.); (A.F.); (G.S.)
| | - Antoine Chatrenet
- Nephrologie, Centre Hospitalier Le Mans, 72037 Le Mans, France; (T.T.); (A.C.); (C.A.C.d.L.T.); (L.G.); (L.N.); (A.F.); (G.S.)
| | | | - Lurlinys Gendrot
- Nephrologie, Centre Hospitalier Le Mans, 72037 Le Mans, France; (T.T.); (A.C.); (C.A.C.d.L.T.); (L.G.); (L.N.); (A.F.); (G.S.)
| | - Louise Nielsen
- Nephrologie, Centre Hospitalier Le Mans, 72037 Le Mans, France; (T.T.); (A.C.); (C.A.C.d.L.T.); (L.G.); (L.N.); (A.F.); (G.S.)
| | - Antioco Fois
- Nephrologie, Centre Hospitalier Le Mans, 72037 Le Mans, France; (T.T.); (A.C.); (C.A.C.d.L.T.); (L.G.); (L.N.); (A.F.); (G.S.)
| | - Giulia Santagati
- Nephrologie, Centre Hospitalier Le Mans, 72037 Le Mans, France; (T.T.); (A.C.); (C.A.C.d.L.T.); (L.G.); (L.N.); (A.F.); (G.S.)
| | - Patrick Saulnier
- Statistical laboratory, University of Angers, 49035 Angers, France;
| | - Nicola Panocchia
- Nephrology Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Roma, Italy;
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9
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Matsuura R, Hidaka S, Ohtake T, Mochida Y, Ishioka K, Maesato K, Oka M, Moriya H, Kobayashi S. Intradialytic hypotension is an important risk factor for critical limb ischemia in patients on hemodialysis. BMC Nephrol 2019; 20:473. [PMID: 31856757 PMCID: PMC6923908 DOI: 10.1186/s12882-019-1662-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 12/09/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Critical limb ischemia (CLI) and intradialytic hypotension (IDH) are common complications in patients on hemodialysis (HD). However, limited data are available on whether IDH is related to CLI in these patients. The aim of this retrospective study was to evaluate whether IDH is a risk factor for CLI in HD patients. METHODS We examined the frequency of IDH in 147 patients who received HD between January 1 and June 30, 2012. Blood pressure was measured during HD every 30 min and IDH was defined as a ≥ 20 mmHg fall in systolic blood pressure compared to 30 min before and a nadir intradialytic systolic blood pressure < 90 mmHg. The primary study outcome was newly developed CLI requiring revascularization treatment or CLI-related death. We assessed the association of IDH with outcome using a multivariable subdistribution hazard model with adjustment for male, age, smoking and history of cardiovascular disease. RESULTS The median follow-up period was 24.5 months. Fifty patients (34%) had episodes of IDH in the study entry period. During follow-up, 14 patients received endovascular treatment and CLI-related death occurred in 1 patient. Factors associated with incident CLI in univariate analysis were age, smoking, diabetes mellitus, peripheral arterial disease, history of cardiovascular disease, and IDH. IDH was significantly associated with the outcome with the subdistribution hazard ratio of 3.13 [95% confidence interval, 1.05-9.37]. CONCLUSIONS IDH was an independent risk factor for incident CLI in patients on HD.
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Affiliation(s)
- Ryo Matsuura
- Kidney Disease and Transplant Center, Shonan Kamakura General Hospital, 1370-1, Okamoto, Kamakura, 247-8533, Japan.,Department of Nephrology and Endocrinology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Sumi Hidaka
- Kidney Disease and Transplant Center, Shonan Kamakura General Hospital, 1370-1, Okamoto, Kamakura, 247-8533, Japan.
| | - Takayasu Ohtake
- Kidney Disease and Transplant Center, Shonan Kamakura General Hospital, 1370-1, Okamoto, Kamakura, 247-8533, Japan
| | - Yasuhiro Mochida
- Kidney Disease and Transplant Center, Shonan Kamakura General Hospital, 1370-1, Okamoto, Kamakura, 247-8533, Japan
| | - Kunihiro Ishioka
- Kidney Disease and Transplant Center, Shonan Kamakura General Hospital, 1370-1, Okamoto, Kamakura, 247-8533, Japan
| | - Kyoko Maesato
- Kidney Disease and Transplant Center, Shonan Kamakura General Hospital, 1370-1, Okamoto, Kamakura, 247-8533, Japan
| | - Machiko Oka
- Kidney Disease and Transplant Center, Shonan Kamakura General Hospital, 1370-1, Okamoto, Kamakura, 247-8533, Japan
| | - Hidekazu Moriya
- Kidney Disease and Transplant Center, Shonan Kamakura General Hospital, 1370-1, Okamoto, Kamakura, 247-8533, Japan
| | - Shuzo Kobayashi
- Kidney Disease and Transplant Center, Shonan Kamakura General Hospital, 1370-1, Okamoto, Kamakura, 247-8533, Japan
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10
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Yokoyama K, Shimazaki R, Fukagawa M, Akizawa T. Long-Term Efficacy and Safety of Evocalcet in Japanese Patients with Secondary Hyperparathyroidism Receiving Hemodialysis. Sci Rep 2019; 9:6410. [PMID: 31015494 PMCID: PMC6478860 DOI: 10.1038/s41598-019-42017-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 03/22/2019] [Indexed: 01/11/2023] Open
Abstract
Secondary hyperparathyroidism (SHPT) is a common complication of chronic kidney disease (CKD), and as the disease progresses SHPT is associated with systemic consequences, termed CKD-mineral and bone disorder. Currently, cinacalcet is indicated for the treatment of SHPT; however, cinacalcet is associated with upper gastrointestinal adverse events. Evocalcet has been developed to address these issues, but the long-term safety and efficacy of evocalcet need to be evaluated. To more accurately reflect clinical practice, this phase 3, multicenter, open-label study was specifically designed without a cinacalcet washout period, and focused on those patients who switched from cinacalcet to evocalcet. A total of 137 SHPT patients undergoing hemodialysis were enrolled, of whom 113 switched from cinacalcet to evocalcet. The most frequent type of adverse drug reaction was decreased adjusted calcium. The incidence of gastrointestinal-related adverse events did not increase in a dose-dependent manner as the dose of evocalcet was increased. The percentage of patients achieving the target intact parathyroid hormone concentration increased from 40.9% to 72.3% with 52-week treatment. The corrected serum calcium and phosphorus levels remained largely unchanged throughout the study. The long-term safety and efficacy of evocalcet was confirmed using a clinically relevant intra-subject dose-adjustment strategy in SHPT patients undergoing hemodialysis.
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Affiliation(s)
- Keitaro Yokoyama
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Ryutaro Shimazaki
- R&D Division, Kyowa Hakko Kirin Co., Ltd., 1-9-2 Otemachi, Chiyoda-ku, Tokyo, 100-0004, Japan
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara-shi, Kanagawa, 259-1193, Japan
| | - Tadao Akizawa
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Namics 301, 4-24-51 Takanawa, Minato-ku, Tokyo, 108-0074, Japan
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11
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Tsuruya K, Shimazaki R, Fukagawa M, Akizawa T. Efficacy and safety of evocalcet in Japanese peritoneal dialysis patients. Clin Exp Nephrol 2019; 23:739-748. [PMID: 30955188 PMCID: PMC6586709 DOI: 10.1007/s10157-019-01692-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 01/06/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Secondary hyperparathyroidism (SHPT) is a serious and common complication in patients receiving peritoneal dialysis (PD). Cinacalcet is currently the recommended therapy for SHPT; however, gastrointestinal (GI)-related symptoms can result in low adherence and high discontinuation rates. Evocalcet is a novel calcimimetic agent that has non-inferior efficacy while providing a more tolerable safety profile. METHODS This was a multicenter, intra-subject dose-adjustment treatment study evaluating the efficacy and safety of 1-8 mg evocalcet orally administered once daily for 32 weeks for the treatment of SHPT in PD patients. Patients then entered a 20-week extension period (dose range 1-12 mg). The primary endpoint was the proportion of patients who achieved a mean intact parathyroid hormone (iPTH) level of 60-240 pg/mL during the evaluation period (weeks 30-32). Secondary efficacy endpoints included the proportion of patients achieving ≥ 30% decrease in iPTH levels. RESULTS A total of 39 Japanese PD patients with SHPT received evocalcet. The target mean iPTH level of 60-240 pg/mL was achieved by 71.8% (28/39) of patients during the evaluation period and 83.3% (20/24) of patients at week 52. The proportion of patients who achieved ≥ 30% decrease in iPTH levels from baseline was 74.4% (29/39) during the evaluation period and 87.5% (21/24) at week 52. Adverse drug reactions occurred in 46.2% (18/39) of patients, with most being of mild-to-moderate severity including GI-related events. CONCLUSION This study shows the long-term efficacy and safety of evocalcet when orally administered to PD patients with SHPT once daily. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov: NCT02549417, https://clinicaltrials.gov/ct2/show/NCT02549417 ; JAPIC: JapicCTI-153016, http://www.clinicaltrials.jp/user/showCteDetailE.jsp?japicId=JapicCTI-153016 .
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Affiliation(s)
- Kazuhiko Tsuruya
- Department of Nephrology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8521, Japan.
| | - Ryutaro Shimazaki
- R&D Division, Kyowa Hakko Kirin Co., Ltd., 1-9-2 Otemachi, Chiyoda-ku, Tokyo, 100-0004, Japan
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Tadao Akizawa
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Namics 301, 4-24-51 Takanawa, Minato-ku, Tokyo, 108-0074, Japan
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12
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Akizawa T, Shimazaki R, Fukagawa M. Phase 2b study of evocalcet (KHK7580), a novel calcimimetic, in Japanese patients with secondary hyperparathyroidism undergoing hemodialysis: A randomized, double-blind, placebo-controlled, dose-finding study. PLoS One 2018; 13:e0204896. [PMID: 30379826 PMCID: PMC6209414 DOI: 10.1371/journal.pone.0204896] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 08/17/2018] [Indexed: 01/18/2023] Open
Abstract
Background Evocalcet has been developed as a new calcimimetic agent for hemodialysis (HD) patients with secondary hyperparathyroidism (HDSHPT), eliciting fewer gastrointestinal symptoms and drug interactions. We evaluated the efficacy, safety, and optimal starting dose of evocalcet in HDSHPT. Methods In this 3-week, Phase 2b, randomized, double-blind, placebo-controlled, multicenter, parallel-group, dose-finding study, Japanese HDSHPT with intact parathyroid hormone (iPTH) ≥240 pg/mL and serum calcium level corrected for albumin ≥8.4 mg/dL were randomized to evocalcet 0.5, 1, 2 mg/day administered orally or placebo under double-blind conditions, and cinacalcet 25 mg/day (open-label conditions). Results In total, 152 HDSHPT were randomized. The mean ± standard deviation (median, interquartile range) of percent changes in iPTH from baseline to end of treatment were −8.40±25.43% (−12.16, 39.60), −10.56±22.86% (−14.24, 27.85), and −20.16±34.23% (−23.83, 39.05) in the evocalcet 0.5, 1, and 2 mg/day groups and 5.44±25.85% (3.52, 35.39) and −25.86±27.76% (−29.79, 34.15) in the placebo and cinacalcet groups, respectively. The dose-response profile for each evocalcet group vs placebo showed statistically significant differences for all contrast patterns. Whole PTH, corrected calcium, ionized calcium, phosphorus, and intact fibroblast growth factor 23 decreased after treatment initiation in the evocalcet and cinacalcet groups. Adverse events were observed in 30%–50% of patients (all groups). Incidence of adverse events was similar among all groups except for decreased calcium, which occurred more frequently in the evocalcet 2 mg and cinacalcet groups. Conclusions The dose response and safety of all administered doses of evocalcet were confirmed, as well as the efficacy of evocalcet ≥1 mg in a strictly Japanese sample of HDSHPT. Therefore, evocalcet 1 mg was considered appropriate as an initial dose for HDSHPT.
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Affiliation(s)
- Tadao Akizawa
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Namics 301, Takanawa, Minato-ku, Tokyo, Japan
- * E-mail:
| | | | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
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13
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Mima A, Tansho K, Nagahara D, Watase K. Treatment of secondary hyperparathyroidism in patients on hemodialysis using a novel synthetic peptide calcimimetic, etelcalcetide: a short-term clinical study. J Int Med Res 2018; 46:4578-4585. [PMID: 30027791 PMCID: PMC6259360 DOI: 10.1177/0300060518786913] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective Secondary hyperparathyroidism (SHPT) is a major complication in patients with chronic kidney disease (CKD). SHPT is related to chronic kidney disease-mineral bone disorder, leading to increased morbidity and mortality. Etelcalcetide is intravenously administered at the end of hemodialysis (HD). Etelcalcetide differs from the oral calcimimetic cinacalcet because it reduces gastrointestinal adverse events, thereby improving therapeutic effects. Etelcalcetide has only been approved by the U.S. Food and Drug Administration for several months. Therefore, there have only been a few reports regarding treatment of SHPT using etelcalcetide. This study aimed to evaluate the efficacy of etelcalcetide in patients on HD with SHPT. Methods Nine patients on HD (four men and five women, aged 58 ± 10 years) were enrolled in this study. All of the patients received etelcalcetide (5–10 mg, three times a week after HD). The observation period was 4.4 ± 1.0 months. Results All of the patients showed a significant reduction in serum parathyroid hormone levels during the observation period (−59% ± 20%). No significant adverse effects were observed. Conclusions Although this study had an uncontrolled small group and a short observation period, our results suggest that etelcalcetide could be a promising agent for SHPT treatment.
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Affiliation(s)
- Akira Mima
- Deapartment of Nephrology, Kindai University Nara Hospital, Kindai University Faculty of Medicine, Nara, Japan
| | - Kosuke Tansho
- Deapartment of Nephrology, Kindai University Nara Hospital, Kindai University Faculty of Medicine, Nara, Japan
| | - Dai Nagahara
- Deapartment of Nephrology, Kindai University Nara Hospital, Kindai University Faculty of Medicine, Nara, Japan
| | - Kenji Watase
- Deapartment of Nephrology, Kindai University Nara Hospital, Kindai University Faculty of Medicine, Nara, Japan
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14
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Friedl C, Zitt E. Role of etelcalcetide in the management of secondary hyperparathyroidism in hemodialysis patients: a review on current data and place in therapy. DRUG DESIGN DEVELOPMENT AND THERAPY 2018; 12:1589-1598. [PMID: 29910605 PMCID: PMC5989700 DOI: 10.2147/dddt.s134103] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Secondary hyperparathyroidism (sHPT) is a frequently occurring severe complication of advanced kidney disease. Its clinical consequences include extraskeletal vascular and valvular calcifications, changes in bone metabolism resulting in renal osteodystrophy, and an increased risk of cardiovascular morbidity and mortality. Calcimimetics are a cornerstone of parathyroid hormone (PTH)-lowering therapy, as confirmed by the recently updated 2017 Kidney Disease: Improving Global Outcomes chronic kidney disease – mineral and bone disorder clinical practice guidelines. Contrary to calcitriol or other vitamin D-receptor activators, calcimimetics reduce PTH without increasing serum-calcium, phosphorus, or FGF23 levels. Etelcalcetide is a new second-generation calcimimetic that has been approved for the treatment of sHPT in adult hemodialysis patients. Whereas the first-generation calcimimetic cinacalcet is taken orally once daily, etelcalcetide is given intravenously thrice weekly at the end of the hemodialysis session. Apart from improving drug adherence, etelcalcetide has proven to be more effective in lowering PTH when compared to cinacalcet, with an acceptable and comparable safety profile. The hope for better gastrointestinal tolerance with intravenous administration did not come true, as etelcalcetide did not significantly mitigate the adverse gastrointestinal effects associated with cinacalcet. Enhanced adherence and strong reductions in PTH, phosphorus, and FGF23 could set the stage for a future large randomized controlled trial to demonstrate that improved biochemical control of mineral metabolism with etelcalcetide in hemodialysis patients translates into cardiovascular and survival benefits and better health-related quality of life.
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Affiliation(s)
- Claudia Friedl
- Department of Internal Medicine, Clinical Division of Nephrology, Medical University of Graz, Graz
| | - Emanuel Zitt
- Department of Internal Medicine III, Nephrology and Dialysis, Feldkirch Academic Teaching Hospital, Feldkirch, Austria
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15
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Eidman KE, Wetmore JB. Managing hyperparathyroidism in hemodialysis: role of etelcalcetide. Int J Nephrol Renovasc Dis 2018; 11:69-80. [PMID: 29440923 PMCID: PMC5804266 DOI: 10.2147/ijnrd.s128252] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Secondary hyperparathyroidism (SHPT) is common in patients receiving maintenance hemodialysis and is associated with adverse outcomes. Currently, SHPT is managed by reducing circulating levels of phosphate with oral binders and parathyroid hormone (PTH) with vitamin D analogs and/or the calcimimetic cinacalcet. Etelcalcetide, a novel calcimimetic administered intravenously (IV) at the end of a hemodialysis treatment session, effectively reduces PTH in clinical trials when given thrice weekly. Additional clinical effects include reductions in circulating levels of phosphate and FGF-23 and an improved profile of markers of bone turnover. However, despite being administered IV, etelcalcetide appears to be associated with rates of nausea and vomiting comparable to those of cinacalcet. Additionally, etelcalcetide, relative to placebo, causes hypocalcemia and prolonged electrocardiographic QT intervals, effects that must be considered when contemplating its use. Etelcalcetide likely has a role in treating hemodialysis patients with uncontrolled SHPT or with hypercalcemia or hyperphosphatemia receiving activated vitamin D compounds. However, its use should be at least partially constrained by consideration of the risk of hypocalcemia and resultant prolonged QT intervals in vulnerable patients. Because of its effectiveness as a PTH-reducing agent administered in the dialysis unit, etelcalcetide represents a potentially promising new therapeutic approach to the often vexing problem of SHPT in hemodialysis patients. However, whether its use is associated with changes in surrogate clinical end points, such as effects on rates of parathyroidectomy, fracture, vascular calcification, or mortality or on quality of life, remains to be studied.
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Affiliation(s)
- Keith E Eidman
- Division of Nephrology, Hennepin County Medical Center, University of Minnesota, Minneapolis, MN
| | - James B Wetmore
- Division of Nephrology, Hennepin County Medical Center, University of Minnesota, Minneapolis, MN
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN, USA
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16
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Pereira L, Meng C, Marques D, Frazão JM. Old and new calcimimetics for treatment of secondary hyperparathyroidism: impact on biochemical and relevant clinical outcomes. Clin Kidney J 2017; 11:80-88. [PMID: 29423207 PMCID: PMC5798074 DOI: 10.1093/ckj/sfx125] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 08/18/2017] [Indexed: 12/22/2022] Open
Abstract
Secondary hyperparathyroidism (SHPT) is associated with increased bone turnover, risk of fractures, vascular calcifications, and cardiovascular and all-cause mortality. The classical treatment for SHPT includes active vitamin D compounds and phosphate binders. However, achieving the optimal laboratory targets is often difficult because vitamin D sterols suppress parathyroid hormone (PTH) secretion, while also promoting calcium and phosphate intestinal absorption. Calcimimetics increase the sensitivity of the calcium-sensing receptor, so that even with lower levels of extracellular calcium a signal can still exist, leading to a decrease of the set-point for systemic calcium homeostasis. This enables a decrease in plasma PTH levels and, consequently, of calcium levels. Cinacalcet was the first calcimimetic to be approved for clinical use. More than 10 years since its approval, cinacalcet has been demonstrated to effectively reduce PTH and improve biochemical control of mineral and bone disorders in chronic kidney patients. Three randomized controlled trials have analysed the effects of treatment with cinacalcet on hard clinical outcomes such as vascular calcification, bone histology and cardiovascular mortality and morbidity. However, a final conclusion on the effect of cinacalcet on hard outcomes remains elusive. Etelcalcetide is a new second-generation calcimimetic with a pharmacokinetic profile that allows thrice-weekly dosing at the time of haemodialysis. It was recently approved in Europe, and is regarded as a second opportunity to improve outcomes by optimizing treatment for SHPT. In this review, we summarize the impact of cinacalcet with regard to biochemical and clinical outcomes. We also discuss the possible implications of the new calcimimetic etelcalcetide in the quest to improve outcomes.
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Affiliation(s)
- Luciano Pereira
- Institute of Investigation and Innovation in Health, University of Porto, Porto, Portugal.,Nephrology and Infeciology group, INEB-National Institute of Biomedical Engineer, University of Porto, Porto, Portugal.,Department of Nephrology, São João Hospital Center, Porto, Portugal.,DaVita Kidney Care, Porto, Portugal
| | - Catarina Meng
- Institute of Investigation and Innovation in Health, University of Porto, Porto, Portugal.,Nephrology and Infeciology group, INEB-National Institute of Biomedical Engineer, University of Porto, Porto, Portugal.,Department of Nephrology, São João Hospital Center, Porto, Portugal
| | | | - João M Frazão
- Institute of Investigation and Innovation in Health, University of Porto, Porto, Portugal.,Nephrology and Infeciology group, INEB-National Institute of Biomedical Engineer, University of Porto, Porto, Portugal.,Department of Nephrology, São João Hospital Center, Porto, Portugal.,DaVita Kidney Care, Porto, Portugal
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17
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Shigematsu T, Fukagawa M, Yokoyama K, Akiba T, Fujii A, Odani M, Akizawa T. Long-term effects of etelcalcetide as intravenous calcimimetic therapy in hemodialysis patients with secondary hyperparathyroidism. Clin Exp Nephrol 2017; 22:426-436. [PMID: 28836058 DOI: 10.1007/s10157-017-1442-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 07/03/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Secondary hyperparathyroidism (SHPT) is a serious major complication in hemodialysis patients with chronic kidney disease. Long-term maintenance of serum phosphate, calcium, and parathyroid hormone (PTH) levels in appropriate ranges in these patients is a major challenge. We investigated the efficacy and safety of long-term treatment with etelcalcetide, a novel intravenous calcimimetic, in Japanese SHPT patients on long-term hemodialysis. METHODS This study was a multicenter open-label study. A total of 191 hemodialysis patients with serum intact PTH (iPTH) > 240 pg/mL were enrolled. Etelcalcetide was administered thrice weekly for 52 weeks, with an initial dose of 5 mg and flexibility to adjust the dose between 2.5 and 15 mg and to adjust the dosing of concomitant medications for SHPT. The efficacy endpoint was the proportion of patients with serum iPTH decreased to the target range (60-240 pg/mL). RESULTS Serum iPTH levels decreased immediately after etelcalcetide was started. At the end of the study, 87.5% (95% confidence interval 81.4-92.2; 140/160 patients) of patients achieved target serum iPTH levels, with control of serum calcium and phosphate levels. Adverse events, mostly mild to moderate, were reported by 96.8% of patients and led to study discontinuation in 7.4% of patients. Nausea, vomiting, and symptomatic hypocalcemia were found in 4.7, 9.5, and 1.1%, with 0.5, 1.1, and 1.1% considered treatment-related. CONCLUSIONS Etelcalcetide effectively maintained serum iPTH, calcium, and phosphate levels in appropriate ranges with concomitant medications for SHPT for 52 weeks in Japanese hemodialysis patients, and was safe and well tolerated. REGISTRATION NUMBER JapicCTI-142665.
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Affiliation(s)
- Takashi Shigematsu
- Department of Nephrology, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan.
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Japan
| | - Keitaro Yokoyama
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | | | - Akifumi Fujii
- Clinical Development Planning, Ono Pharmaceutical Co. Ltd, Osaka, Japan
| | - Motoi Odani
- Data Science, Ono Pharmaceutical Co. Ltd, Osaka, Japan
| | - Tadao Akizawa
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
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18
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Fukagawa M, Komaba H. Chronic Kidney Disease-Mineral and Bone Disorder in Asia. KIDNEY DISEASES (BASEL, SWITZERLAND) 2017; 3:1-7. [PMID: 28785558 PMCID: PMC5527178 DOI: 10.1159/000470909] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 03/14/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Chronic kidney disease-mineral and bone disorder (CKD-MBD) is one of the most common complications in patients with CKD. As CKD-MBD is a systemic syndrome, prevention and management should be aimed at achieving better survival and less risk of cardiovascular events and fractures. SUMMARY Although target ranges for serum markers of mineral metabolism have been proposed in several global or local guidelines, these were mostly based on data from non-Asian patients. Additionally, there remain differences in medical and social systems as well as in economic status, even among Asian countries and areas. KEY MESSAGE Asian CKD patient data needs to be analyzed, published, and shared to establish optimal local strategies for CKD-MBD management.
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Affiliation(s)
- Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara, Japan
| | - Hirotaka Komaba
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara, Japan
- The Institute of Medical Sciences, Tokai University, Isehara, Japan
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19
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Management of secondary hyperparathyroidism: how and why? Clin Exp Nephrol 2017; 21:37-45. [PMID: 28044233 DOI: 10.1007/s10157-016-1369-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 11/29/2016] [Indexed: 12/20/2022]
Abstract
Secondary hyperparathyroidism (SHPT) is a common complication in chronic kidney disease. Currently, various treatment options are available, including vitamin D receptor activators, cinacalcet hydrochloride, and parathyroidectomy. These treatment options have contributed to the successful control of SHPT, and recent clinical studies have provided evidence suggesting that effective treatment of SHPT leads to improved survival. Although bone disease is the most widely recognized consequence of SHPT and remains a major target for treatment of SHPT, there is increasing evidence that parathyroid hormone (PTH) and fibroblast growth factor 23 (FGF23), both of which are markedly elevated in SHPT, have multiple adverse effects on extraskeletal tissues. These actions may lead to the pathological development of left ventricular hypertrophy, renal anemia, immune dysfunction, inflammation, wasting, muscle atrophy, and urate accumulation. Given that treatment of SHPT leads to decreases in both PTH and FGF23, these data provide an additional rationale for treating SHPT. However, definitive evidence is still lacking, and future research should focus on whether treatment of SHPT prevents the adverse effects of PTH and FGF23.
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Harada K, Inoue A, Yamauchi A, Fujii A. [The pharmacological profile and the clinical efficacy of the world's 1st intravenous calcimimetics; etelcalcetide hydrochloride (Parsabiv ®)]. Nihon Yakurigaku Zasshi 2017; 150:98-113. [PMID: 28794306 DOI: 10.1254/fpj.150.98] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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