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Bernardor J, Flammier S, Zagozdzon I, Lalayiannis AD, Koster-Kamphuis L, Verrina E, Dorresteijn E, Guzzo I, Haffner D, Shroff R, Schmitt CP, Bacchetta J. Safety and Efficacy of Cinacalcet in Children Aged Under 3 Years on Maintenance Dialysis. Kidney Int Rep 2024; 9:2096-2109. [PMID: 39081774 PMCID: PMC11284406 DOI: 10.1016/j.ekir.2024.04.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 04/24/2024] [Accepted: 04/29/2024] [Indexed: 08/02/2024] Open
Abstract
Introduction Secondary hyperparathyroidism (sHPT) is particularly severe in rapidly growing infants in dialysis. Although cinacalcet is effective and licensed in dialysis in children aged >3 years, its efficacy and safety for children aged <3 years is unknown. Methods We identified 26 children aged <3 years who were on dialysis and treated with cinacalcet between 2009 and 2021 in 8 European pediatric centers. Results Median (interquartile range) age at the start of cinacalcet was 18 (interquartile range: 11-27) months, serum parathyroid hormone (PTH) was 792 (411-1397) pg/ml, corresponding to 11.6 (5.9-19.8) times the upper limit of normal (ULN). Serum calcium was 2.56 (2.43-2.75) mmol/l, and serum phosphate 1.47 (1.16-1.71) mmol/l. Serum 25-OH vitamin D (25-OHD) was 70 (60-89) nmol/l, 3 children were vitamin D deficient (<50 nmol/l). The initial cinacalcet dose was 0.4 (0.2-0.8) mg/kg/d and the maximum dose was 1.1 (0.6-1.2) mg/kg/d. The median follow-up under cinacalcet was 1.2 (0.7-2.0) years. PTH decreased to 4.3 (2.2-7.8) times the ULN after 6 months, to 2.0 (1.0-5.3) times ULN after 12 months, and to 1.6 (0.5-3.4) times thereafter (P = 0.017/0.003/<0.0001, log-transformed PTH). Seven of the 26 infants developed 10 hypocalcemic episodes <2.10 mmol/l. Oral calcium intake was 84% (66%-117%) of recommended nutrient intake at start, 100% (64%-142%) at 3 months and declined to 78% (65%-102%) at 12 months of therapy. Three children developed clinical signs of precocious puberty. Conclusion Cinacalcet efficiently controlled severe sHPT in children aged <3 years and was associated with hypocalcemic episodes (similar to what is observed in older children) and precious puberty, thereby mandating meticulous control of calcium (considering nutrition, supplementation, and dialysate) and endocrine changes.
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Affiliation(s)
- Julie Bernardor
- Department of Pediatric Nephrology, Rheumatology and Dermatology, Reference Center for Rare Renal Diseases, Reference Center for Rare Diseases of Phosphate and Calcium, Femme Mère Enfant Hospital, Hospices Civils de Lyon, Lyon, France
- INSERM 1033 Research Unit, Université Claude Bernard Lyon 1, Lyon, France
- Department of Pediatric Nephrology, CHU de Nice, Hôpital Archet, Nice, France
- Centre for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld, Heidelberg, Germany
| | - Sacha Flammier
- Department of Pediatric Nephrology, Rheumatology and Dermatology, Reference Center for Rare Renal Diseases, Reference Center for Rare Diseases of Phosphate and Calcium, Femme Mère Enfant Hospital, Hospices Civils de Lyon, Lyon, France
| | - Ilona Zagozdzon
- Department of Pediatrics, Nephrology and Hypertension, Medical University of Gdańsk, Poland
| | | | - Linda Koster-Kamphuis
- Department of Pediatric Nephrology, University Medical Center, St. Radboud/Radboud University, Nijmegen, The Netherlands
| | - Enrico Verrina
- Division of Nephrology, Dialysis, and Transplantation, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Eiske Dorresteijn
- Department of Pediatric Nephrology, Sophia Children’s Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Isabella Guzzo
- Division of Nephrology, Dialysis and Transplantation, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Pediatric Research Center, Hannover Medical School, Hannover, Germany
| | - Rukshana Shroff
- Pediatric Nephrology Unit, University College London Great Ormond Street Hospital for Children and Institute of Child Health, London, UK
| | - Claus P. Schmitt
- Centre for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld, Heidelberg, Germany
| | - Justine Bacchetta
- Department of Pediatric Nephrology, Rheumatology and Dermatology, Reference Center for Rare Renal Diseases, Reference Center for Rare Diseases of Phosphate and Calcium, Femme Mère Enfant Hospital, Hospices Civils de Lyon, Lyon, France
- INSERM 1033 Research Unit, Université Claude Bernard Lyon 1, Lyon, France
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Zamoner SMS, Takase HM, Riyuzo MC, Caramori JCT, de Andrade LGM. Safety of cinacalcet in children and adolescents with chronic kidney disease-mineral bone disorder: systematic review and proportional meta-analysis of case series. Int Urol Nephrol 2024; 56:1669-1676. [PMID: 37964112 PMCID: PMC11001724 DOI: 10.1007/s11255-023-03844-2] [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: 06/18/2023] [Accepted: 10/08/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND Mineral and bone disease in children with chronic kidney disease can cause abnormalities in calcium, phosphorus, parathyroid hormone, and vitamin D and when left untreated can result in impaired growth, bone deformities, fractures, and vascular calcification. Cinacalcet is a calcimimetic widely used as a therapy to reduce parathyroid hormone levels in the adult population, with hypocalcemia among its side effects. The analysis of safety in the pediatric population is questioned due to the scarcity of randomized clinical trials in this group. OBJECTIVE To assess the onset of symptomatic hypocalcemia or other adverse events (serious or non-serious) with the use of cinacalcet in children and adolescents with mineral and bone disorder in chronic kidney disease. DATA SOURCES AND STUDY ELIGIBILITY CRITERIA The bibliographic search identified 2699 references from 1927 to August/2023 (57 LILACS, 44 Web of Science, 686 PubMed, 131 Cochrane, 1246 Scopus, 535 Embase). Four references were added from the bibliography of articles found and 12 references from the gray literature (Clinical Trials). Of the 77 studies analyzed in full, 68 were excluded because they did not meet the following criteria: population, types of studies, medication, publication types and 1 article that did not present results (gray literature). PARTICIPANTS AND INTERVENTIONS There were 149 patients aged 0-18 years old with Chronic Kidney Disease and mineral bone disorder who received cinacalcet. STUDY APPRAISAL AND SYNTHESIS METHODS Nine eligible studies were examined for study type, size, intervention, and reported outcomes. RESULTS There was an incidence of 0.2% of fatal adverse events and 16% of serious adverse events (p < 0.01 and I2 = 69%), in addition to 10.7% of hypocalcemia, totaling 45.7% of total adverse events. LIMITATIONS There was a bias in demographic information and clinical characteristics of patients in about 50% of the studies and the majority of the studies were case series. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS If used in the pediatric population, the calcimimetic cinacalcet should be carefully monitored for serum calcium levels and attention to possible adverse events, especially in children under 50 months. SYSTEMATIC REVIEW REGISTRATION NUMBER (PROSPERO REGISTER) CRD42019132809.
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Affiliation(s)
- Soraya Mayumi Sasaoka Zamoner
- Botucatu School of Medicine, Pediatrics Department - Pediatric Nephrology, University São Paulo State-UNESP, District of Rubiao Junior, Botucatu, SP, 18618-970, Brazil.
- Clinics Hospital - Botucatu School of Medicine, District of Rubiao Junior, Botucatu, SP, 18618-970, Brazil.
| | - Henrique Mochida Takase
- Botucatu School of Medicine, Pediatrics Department - Pediatric Nephrology, University São Paulo State-UNESP, District of Rubiao Junior, Botucatu, SP, 18618-970, Brazil
- Clinics Hospital - Botucatu School of Medicine, District of Rubiao Junior, Botucatu, SP, 18618-970, Brazil
| | - Marcia Camegaçava Riyuzo
- Botucatu School of Medicine, Pediatrics Department - Pediatric Nephrology, University São Paulo State-UNESP, District of Rubiao Junior, Botucatu, SP, 18618-970, Brazil
- Clinics Hospital - Botucatu School of Medicine, District of Rubiao Junior, Botucatu, SP, 18618-970, Brazil
| | - Jacqueline Costa Teixeira Caramori
- Botucatu School of Medicine, Internal Medicine Department - Nephrology, University São Paulo State-UNESP, District of Rubiao Junior, Botucatu, SP, 18618-970, Brazil
- Clinics Hospital - Botucatu School of Medicine, District of Rubiao Junior, Botucatu, SP, 18618-970, Brazil
| | - Luis Gustavo Modelli de Andrade
- Botucatu School of Medicine, Internal Medicine Department - Nephrology, University São Paulo State-UNESP, District of Rubiao Junior, Botucatu, SP, 18618-970, Brazil
- Clinics Hospital - Botucatu School of Medicine, District of Rubiao Junior, Botucatu, SP, 18618-970, Brazil
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Phase 1, single-dose study to assess the safety, tolerability, pharmacokinetics, and pharmacodynamics of etelcalcetide in pediatric patients with secondary hyperparathyroidism receiving hemodialysis. Pediatr Nephrol 2021; 36:133-142. [PMID: 32647975 DOI: 10.1007/s00467-020-04599-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 04/29/2020] [Accepted: 05/04/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Data on the safety, efficacy of etelcalcetide in children with secondary hyperparathyroidism (sHPT) are limited. METHODS This phase 1 study (NCT02833857) evaluated the safety, tolerability, pharmacokinetics (PK), pharmacodynamics (PD) of single-dose etelcalcetide (0.035 mg/kg intravenously) in pediatric hemodialysis patients (two cohorts; 1: 12-< 18 years; 2: 2-< 12 years). Treatment-emergent adverse events (AEs), PK/PD were assessed post-dose on D1 at 10 min and 4 h, on multiple days until D10, and at end of study (D30). RESULTS Etelcalcetide administered to 11 patients (mean [SD] age 10.3 [4.3] years; cohort 1, n = 6; cohort 2, n = 5) was well tolerated. AEs were consistent with established safety profiles in adults. Two patients (1 per cohort) reported treatment-related AEs (cohort 1: hypocalcemia; cohort 2: headache, paresthesia, vomiting). No serious AEs or deaths were reported. Mean serum corrected calcium (cCa) for all patients was maintained > 2.25 mmol/L. After etelcalcetide dosing, PK exposures declined, with mean Cmax, AUClast, and AUCinf exposures higher in cohort 1. Median percent change in serum intact parathyroid hormone (iPTH) from baseline (cohort 1: 51.2 pmol/L; cohort 2: 84.0 pmol/L) reached the nadir on D1 at 4 h (cohort 1: - 33.4%; cohort 2: - 64.2%). Mean total calcium and cCa reached nadirs on D3 at 2.39 mmol/L, and ionized Ca on D1 at 4 h. CONCLUSIONS Single-dose etelcalcetide (0.035 mg/kg) was well tolerated with expected PK and safety profiles. Overall pattern of changes in serum iPTH and serum calcium was similar between cohorts and consistent with expected responses to etelcalcetide.
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Warady BA, Ng E, Bloss L, Mo M, Schaefer F, Bacchetta J. Cinacalcet studies in pediatric subjects with secondary hyperparathyroidism receiving dialysis. Pediatr Nephrol 2020; 35:1679-1697. [PMID: 32367309 PMCID: PMC7385021 DOI: 10.1007/s00467-020-04516-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 02/18/2020] [Accepted: 02/21/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Secondary hyperparathyroidism (sHPT), a complication of chronic kidney disease (CKD) characterized by persistently elevated parathyroid hormone (PTH), alterations in calcium-phosphorus homeostasis, and vitamin D metabolism, affects 50% of children receiving dialysis. A significant proportion of these children develop CKD-mineral and bone disorder (CKD-MBD), associated with an increased risk of fractures and vascular calcification. The standard of care for sHPT in children includes vitamin D sterols, calcium supplementation, and phosphate binders. Several agents are approved for sHPT treatment in adults undergoing dialysis, including vitamin D analogs and calcimimetics, with limited information on their safety and efficacy in children. The calcimimetic cinacalcet is approved for use in adults with sHPT on dialysis, but is not approved for pediatric use outside Europe. METHODS This review provides dosing, safety, and efficacy information from Amgen-sponsored cinacalcet pediatric trials and data from non-Amgen sponsored clinical studies. RESULTS The Amgen cinacalcet pediatric clinical development program consisted of two Phase 3 randomized studies, one Phase 3 single arm extension study, one open-label Phase 2 study, and two open-label Phase 1 studies. Effects of cinacalcet on PTH varied across studies. Overall, 7.4 to 57.1% of subjects who received cinacalcet in an Amgen clinical trial attained PTH levels within recommended target ranges and 22.2 to 70.6% observed a ≥ 30% reduction in PTH. In addition, significant reductions in PTH were demonstrated in all non-Amgen-supported studies. CONCLUSIONS To help inform the pediatric nephrology community, this manuscript contains the most comprehensive review of cinacalcet usage in pediatric CKD patients to date.
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Affiliation(s)
- Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, MO, USA.
| | - Eric Ng
- Amgen Inc., Thousand Oaks, CA, USA
| | | | - May Mo
- Amgen Inc., Thousand Oaks, CA, USA
| | | | - Justine Bacchetta
- Department of Pediatric Nephrology, Rheumatology and Dermatology, Femme Mère Enfant Hospital, Bron, France
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Bacchetta J, Schmitt CP, Ariceta G, Bakkaloglu SA, Groothoff J, Wan M, Vervloet M, Shroff R, Haffner D. Cinacalcet use in paediatric dialysis: a position statement from the European Society for Paediatric Nephrology and the Chronic Kidney Disease-Mineral and Bone Disorders Working Group of the ERA-EDTA. Nephrol Dial Transplant 2020; 35:47-64. [PMID: 31641778 DOI: 10.1093/ndt/gfz159] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Indexed: 12/11/2022] Open
Abstract
Secondary hyperparathyroidism (SHPT) is an important complication of advanced chronic kidney disease (CKD) in children, which is often difficult to treat with conventional therapy. The calcimimetic cinacalcet is an allosteric modulator of the calcium-sensing receptor. It has proven to be effective and safe in adults to suppress parathyroid hormone (PTH), but data on its use in children are limited. To date, studies in children only consist of two randomized controlled trials, nine uncontrolled interventional or observational studies, and case reports that report the efficacy of cinacalcet as a PTH-lowering compound. In 2017, the European Medical Agency approved the use of cinacalcet for the treatment of SHPT in children on dialysis in whom SHPT is not adequately controlled with standard therapy. Since evidence-based guidelines are so far lacking, we present a position statement on the use of cinacalcet in paediatric dialysis patients based on the available evidence and opinion of experts from the European Society for Paediatric Nephrology, Chronic Kidney Disease-Mineral and Bone Disorder and Dialysis Working Groups, and the ERA-EDTA. Given the limited available evidence the strength of these statements are weak to moderate, and must be carefully considered by the treating physician and adapted to individual patient needs as appropriate. Audit and research recommendations to study key outcome measures in paediatric dialysis patients receiving cinacalcet are suggested.
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Affiliation(s)
- Justine Bacchetta
- Reference Center for Rare Diseases of Calcium and Phosphate Metabolism, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France.,Reference Center for Rare Renal Diseases, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France.,INSERM, UMR 1033, Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France.,Lyon Est Medical School, University Lyon 1, Lyon, France
| | - Claus Peter Schmitt
- Pediatric Nephrology, Center for Pediatric and Adolescent Medicine Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Gema Ariceta
- Pediatric Nephrology, Hospital Universitari Vall d'Hebron, Universitat Autónoma of Barcelona, Barcelona, Spain
| | | | - Jaap Groothoff
- Pediatric Nephrology, University of Amsterdam, Amsterdam, The Netherlands
| | - Mandy Wan
- Renal Unit, Great Ormond Street Hospital for Children, London, UK
| | - Marc Vervloet
- Amsterdam UMC, Vrije Universiteit Amsterdam, Nephrology, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Rukshana Shroff
- Renal Unit, Great Ormond Street Hospital for Children, London, UK
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Children's Hospital, Hannover, Germany.,Center for Congenital Kidney Diseases, Center for Rare Diseases, Hannover Medical School, Hannover, Germany
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Al-Ahmad RA, Sheerah AA, Alhasan KA, Kari JA. Cinacalcet use in pediatric chronic kidney disease. A survey study. Saudi Med J 2020; 41:479-484. [PMID: 32373914 PMCID: PMC7253826 DOI: 10.15537/smj.2020.5.25072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 07/04/2020] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To evaluate the practice and attitude of pediatrics nephrologists about cinacalcet use in children. METHODS An electronic structured questionnaire was answered by pediatric nephrologists practicing in the Kingdom of Saudi Arabia (KSA) and Gulf Council countries (GCC). RESULTS A total of 42 pediatric nephrologists responded, of them, 42% used cinacalcet for young children ≤5 years of age and 79% used for children. There were wide variations in the method of administration (examples: crushed, divided, whole tablets), monitoring, doses and response definition, and follow-up. No serious complications after starting cinacalcet was observed in 50%, while 40% reported various complications, mainly hypocalcemia (70%). Cinacalcet was stopped without achieving the target parathyroid hormone in more than half (55%) of children because of intractable adverse effects (40%), poor response (30%), non-adherence (25%), or high cost (5%). CONCLUSION Cinacalcet is used by the majority of pediatric nephrologists in KSA and GCC. A standard clinical guideline is needed to be followed by all users.
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Affiliation(s)
- Rafif A Al-Ahmad
- Department of Pediatrics, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia. E-mail.
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Warady BA, Iles JN, Ariceta G, Dehmel B, Hidalgo G, Jiang X, Laskin B, Shahinfar S, Vande Walle J, Schaefer F. A randomized, double-blind, placebo-controlled study to assess the efficacy and safety of cinacalcet in pediatric patients with chronic kidney disease and secondary hyperparathyroidism receiving dialysis. Pediatr Nephrol 2019; 34:475-486. [PMID: 30506144 DOI: 10.1007/s00467-018-4116-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 10/05/2018] [Accepted: 10/10/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND This randomized phase 3 study evaluated the efficacy and safety of cinacalcet in children with secondary hyperparathyroidism (SHPT) receiving dialysis. METHODS This study had double-blind and open-label phases. Eligible patients aged 6-< 18 years were randomized to cinacalcet (starting dose ≤ 0.20 mg/kg) or placebo. The primary endpoint was ≥ 30% reduction from baseline in mean intact parathyroid hormone (iPTH). Secondary endpoints included mean iPTH ≤ 300 pg/mL; percentage change from baseline in corrected total serum calcium, phosphorus, and calcium phosphorus product (Ca × P); and safety. RESULTS The double-blind phase comprised 43 patients (cinacalcet, n = 22; placebo, n = 21). Nineteen months into the study, regulatory authorities were notified of a fatality; the study was subsequently terminated after a 14-month clinical hold. Before the hold, 12 patients (55%) on cinacalcet and four (19%) on placebo achieved the primary endpoint (p = 0.017), and 27% and 24%, respectively, achieved iPTH ≤ 300 pg/mL. The between-group differences (95% CI) in percentage changes for total serum calcium, phosphorus, and Ca × P were - 4% (- 9 to 1%), - 6% (- 21 to 8%), and - 10% (- 23 to 3%). The mean maximum actual weight-adjusted daily cinacalcet dosage administered was 0.99 mg/kg/day. Overall, 82% of patients on cinacalcet and 86% on placebo had ≥ 1 treatment-emergent adverse event; the most common were vomiting (32%, 24%, respectively), hypocalcemia (23%, 19%), nausea (18%, 14%), and hypertension (14%, 24%). CONCLUSIONS Despite early termination, efficacy and safety outcomes observed with cinacalcet in children with SHPT on dialysis were consistent with adult observations, suggesting cinacalcet may meet an unmet medical need for this population.
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Affiliation(s)
- Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, 2401 Gillham Road, 2MOB.17, Kansas City, MO, 64108, USA.
| | | | - Gema Ariceta
- University Hospital Vall d' Hebron, Barcelona, Spain
| | | | - Guillermo Hidalgo
- Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | | | | | - Shahnaz Shahinfar
- Children's Hospital of Philadelphia, Philadelphia, PA, USA.,S. Shahinfar Consulting Inc., Newtown Square, PA, USA
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VanSickle JS, Srivastava T, Alon US. Use of calcimimetics in children with normal kidney function. Pediatr Nephrol 2019; 34:413-422. [PMID: 29552709 DOI: 10.1007/s00467-018-3935-1] [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: 11/30/2017] [Revised: 02/22/2018] [Accepted: 02/23/2018] [Indexed: 11/26/2022]
Abstract
The calcium-sensing receptor (CaSR) plays an important role in the homeostasis of serum ionized calcium by regulating parathyroid hormone (PTH) secretion and tubular calcium handling. Calcimimetics, which act by allosteric modulation of the CaSR, mimic hypercalcemia resulting in suppression of PTH release and increase in calciuria. Mostly used in children to treat secondary hyperparathyroidism associated with advanced renal failure, we have shown that calcimimetics can also be successfully used in children with bone and mineral disorders in which elevated PTH plays a detrimental role in skeletal pathophysiology in the face of normal kidney function. The current review briefly discusses the role of the CaSR and calcimimetics in calcium homeostasis, and then addresses the potential applications of calcimimetics in children with normal kidney function with disorders in which suppression of PTH is beneficial.
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Affiliation(s)
- Judith Sebestyen VanSickle
- Bone and Mineral Disorders Clinic, Division of Nephrology, Children's Mercy Hospital, University of Missouri at Kansas City, 2401Gillham Road, Kansas City, MO, 64108, USA
| | - Tarak Srivastava
- Bone and Mineral Disorders Clinic, Division of Nephrology, Children's Mercy Hospital, University of Missouri at Kansas City, 2401Gillham Road, Kansas City, MO, 64108, USA
- Renal Research Laboratory, Research and Development, Kansas City VA Medical Center, Kansas City, MO, 64128, USA
| | - Uri S Alon
- Bone and Mineral Disorders Clinic, Division of Nephrology, Children's Mercy Hospital, University of Missouri at Kansas City, 2401Gillham Road, Kansas City, MO, 64108, USA.
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Arenas Morales AJ, DeFreitas MJ, Katsoufis CP, Seeherunvong W, Chandar J, Zilleruelo G, Freundlich M, Abitbol CL. Cinacalcet as rescue therapy for refractory hyperparathyroidism in young children with advanced chronic kidney disease. Pediatr Nephrol 2019; 34:129-135. [PMID: 30203374 DOI: 10.1007/s00467-018-4055-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 08/10/2018] [Accepted: 08/13/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Studies in the use of the calcimimetic, cinacalcet, in pediatric chronic kidney disease (CKD) are few and limited to older children with secondary hyperparathyroidism (sHPT), a major morbid complication contributing to poor growth, bone deformities, and cardiovascular disease. Our objectives were to determine a safe and effective dosing regimen of cinacalcet in the treatment of infants and young children with sHPT that was refractory to standard care and to examine their growth during treatment. METHODS Ten young pediatric patients with advanced CKD were studied retrospectively during 11 courses of treatment with cinacalcet. All had severe sHPT with intact parathyroid hormone (iPTH) levels ≥ 500 pg/ml and were refractory to standard therapy with phosphate binders and active vitamin D analogs at high doses for > 30 days. The cinacalcet dose was advanced by 50% every 2-4 weeks to achieve a decline in the iPTH to a goal of 150-300 pg/ml. Linear growth was assessed at 6-month intervals by change in z-scores (△SDS) for length before and during cinacalcet therapy. RESULTS Median age at initiation of cinacalcet was 18 months (IQR 6, 36) with an average starting dose of 0.7 ± 0.2 mg/kg/day. Median effective dose required to reach iPTH goal of 150-300 pg/ml was 2.8 mg/kg/day (IQR 2.0, 3.1), and time to goal was 112 days (IQR 56, 259) with a median overall decline in iPTH of 82% from baseline by 6 months (p < 0.0001). No subject experienced a clinical adverse event, although 4 had biochemical asymptomatic hypocalcemia. Linear growth improved significantly during cinacalcet therapy (△SDS - 0.62 ± 1.2 versus + 0.91 ± 1.4; p < 0.005). By multiple regression analysis, the primary determinants of growth were concurrent treatment with growth hormone and age < 2 years (R2 = 89.6%; p < 0.001). A shorter treatment time required to achieve iPTH goals also was associated with improved growth (r = - 0.75; p < 0.01). CONCLUSIONS Cinacalcet may be used effectively and safely in infants and small children with refractory sHPT in advanced CKD using a cautious dosing regimen. Cinacalcet successfully brings iPTH to target level and supports growth when other treatments have been ineffective.
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Affiliation(s)
- Aura J Arenas Morales
- Division of Pediatric Nephrology, Holtz Children's Hospital, University of Miami, P.O. Box 016960, Miami, FL, 33130, USA
| | - Marissa J DeFreitas
- Division of Pediatric Nephrology, Holtz Children's Hospital, University of Miami, P.O. Box 016960, Miami, FL, 33130, USA
| | - Chryso P Katsoufis
- Division of Pediatric Nephrology, Holtz Children's Hospital, University of Miami, P.O. Box 016960, Miami, FL, 33130, USA
| | - Wacharee Seeherunvong
- Division of Pediatric Nephrology, Holtz Children's Hospital, University of Miami, P.O. Box 016960, Miami, FL, 33130, USA
| | - Jayanthi Chandar
- Division of Pediatric Nephrology, Holtz Children's Hospital, University of Miami, P.O. Box 016960, Miami, FL, 33130, USA
| | - Gaston Zilleruelo
- Division of Pediatric Nephrology, Holtz Children's Hospital, University of Miami, P.O. Box 016960, Miami, FL, 33130, USA
| | - Michael Freundlich
- Division of Pediatric Nephrology, Holtz Children's Hospital, University of Miami, P.O. Box 016960, Miami, FL, 33130, USA
| | - Carolyn L Abitbol
- Division of Pediatric Nephrology, Holtz Children's Hospital, University of Miami, P.O. Box 016960, Miami, FL, 33130, USA.
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10
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Thomson K, Hutchinson DJ, Chablani L. Stability of extemporaneously prepared cinacalcet oral suspensions. Am J Health Syst Pharm 2018; 75:e236-e240. [PMID: 29691267 DOI: 10.2146/ajhp170072] [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] [Indexed: 12/23/2022] Open
Abstract
PURPOSE The stability of extemporaneously prepared cinacalcet suspensions over 90 days was evaluated. METHODS Cinacalcet 5-mg/mL suspension was prepared by triturating 30-mg cinacalcet tablets. Twelve 30-mL batches were prepared with a 1:1 mixture of Ora-Plus and either Ora-Sweet or Ora-Sweet SF (sugar free). Three suspensions of each kind were stored at both room temperature and refrigerated conditions. A 1-mL sample was taken from each bottle at 0, 7, 18, 32, 64, and 90 days. Each sample was assayed using high-performance liquid chromatography (HPLC). A new HPLC method for evaluating drug peaks of pure cinacalcet was developed. Stability was defined as retention of at least 90% of the initial drug concentration. RESULTS The HPLC method established in this study serves as a novel assay for evaluating cinacalcet oral suspensions. For all suspensions tested at individual conditions, the concentration remained above 90% of the initial concentration for 90 days of storage with the exception of Ora-Plus and Ora-Sweet SF suspensions stored under refrigeration, which were stable for 64 days. Usual sedimentation of the suspensions occurred over time but resolved with agitation; there was no other change in visual appearance of the suspensions over the course of the 90-day study. The color and odor of the suspensions throughout the study remained unchanged with respect to the initial time point. CONCLUSION Extemporaneously compounded cinacalcet 5-mg/mL oral suspensions prepared with a 1:1 mixture of Ora-Plus and either Ora-Sweet or Ora-Sweet SF and stored in 2-oz amber polypropylene plastic bottles were stable for at least 64 days at room temperature and under refrigeration.
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Affiliation(s)
- Kara Thomson
- Wegmans School of Pharmacy, St. John Fisher College, Rochester, NY
| | - David J Hutchinson
- Department of Pharmacy Practice, Wegmans School of Pharmacy, St. John Fisher College, Rochester, NY
| | - Lipika Chablani
- Department of Pharmaceutical Sciences, Wegmans School of Pharmacy, St. John Fisher College, Rochester, NY
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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: 988] [Impact Index Per Article: 141.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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