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Shigematsu T, Asada S, Endo Y, Kawata T, Fukagawa M, Akizawa T. Efficacy and Safety of Evocalcet Evaluated by Dialysate Calcium Concentration in Patients with Secondary Hyperparathyroidism Undergoing Hemodialysis. Int J Nephrol Renovasc Dis 2020; 13:97-106. [PMID: 32494184 PMCID: PMC7229806 DOI: 10.2147/ijnrd.s243210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 03/20/2020] [Indexed: 12/30/2022] Open
Abstract
Purpose Evocalcet is a novel oral calcimimetic drug that has demonstrated similar efficacy to cinacalcet in regulating serum parathyroid hormone (PTH), calcium, and phosphate levels, with fewer upper gastrointestinal tract-related adverse drug reactions (ADRs) in patients with secondary hyperparathyroidism undergoing hemodialysis in Japan. We investigated the efficacy and safety of once-daily oral evocalcet under different dialysate calcium concentrations. Patients and Methods A post hoc analysis by dialysate calcium concentration (2.5, 2.75, and 3.0 mEq/L) was performed using data from a previous Phase 3 study that included cinacalcet as an active control. Efficacy endpoints were the proportion of patients who achieved the target intact PTH levels of ≥60 and ≤240 pg/mL between Week 28 and Week 30; time-course changes in serum intact PTH; calcium and phosphorus levels, bone turnover markers, and fibroblast growth factor 23 (FGF23) over the 30-week study period. Safety endpoints were overall ADRs and hypocalcemia- and upper gastrointestinal tract-related ADRs. Results A total of 634 patients were included in the analysis. Levels of intact PTH, calcium, phosphate, bone turnover markers, and FGF23 showed improvement in all sub-groups, irrespective of dialysate calcium concentration. The incidence of upper gastrointestinal tract-related ADRs was significantly lower in the evocalcet group than the cinacalcet group with dialysate calcium concentrations of 2.75 and 3.0 mEq/L (p<0.05 for both concentrations). Conclusion Evocalcet was effective and safe in regulating the levels of serum intact PTH, calcium, and phosphate in patients with secondary hyperparathyroidism undergoing hemodialysis, irrespective of dialysate calcium concentration.
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Affiliation(s)
| | - Shinji Asada
- Medical Affairs Department, Kyowa Kirin Co., Ltd., Tokyo, Japan
| | - Yuichi Endo
- R&D Division, Kyowa Kirin Co., Ltd., Tokyo, Japan
| | - Takehisa Kawata
- Medical Affairs Department, Kyowa Kirin Co., Ltd., Tokyo, Japan.,R&D Division, Kyowa Kirin Co., Ltd., Tokyo, Japan
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology, and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Tadao Akizawa
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
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Shigematsu T, Fukagawa M, Yokoyama K, Akiba T, Fujii A, Shinoda A, Akizawa T. Influence of dialysate Ca concentrations on the therapeutic effects of etelcalcetide with concomitant drugs in patients with secondary hyperparathyroidism. Nephrology (Carlton) 2019; 25:634-643. [PMID: 31765028 PMCID: PMC7497248 DOI: 10.1111/nep.13682] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 10/30/2019] [Accepted: 11/16/2019] [Indexed: 01/24/2023]
Abstract
Aim Secondary hyperparathyroidism (SHPT), a complication of haemodialysis, is commonly treated with calcimimetics. The impact of dialysates containing different calcium (Ca) concentrations on clinical efficacy of calcimimetics are unclear. We examined whether dialysate Ca concentrations influence the efficacy and dosing of etelcalcetide with concomitant drugs. Methods We performed post hoc analyses of a 52‐week, open‐label, multicentre study of etelcalcetide in Japanese SHPT patients to determine whether dialysate Ca influences the therapeutic effects of etelcalcetide with concomitant drugs. We evaluated the differences in serum intact parathyroid hormone (iPTH), corrected Ca (cCa) and phosphate levels among three dialysate Ca concentration groups (2.5, 2.75 or 3.0 mEq/L Ca). Tartrate‐resistant acid phosphatase 5b (TRACP‐5b) and bone alkaline phosphatase (BAP) levels were also compared. Since the dialysate Ca concentration may influence dose adjustment, we assessed the etelcalcetide and concomitant drug doses. Results There were no clinically meaningful differences in iPTH, cCa and phosphate levels among the 2.5, 2.75 and 3.0 mEq/L groups (n = 34, 64 and 35, respectively) over 52 weeks. At Week 52, more than 82%, 71% and 67% of patients had iPTH, cCa and phosphate levels within target ranges (60‐240 pg/mL, 8.4‐10.0 mg/dL and 3.5‐6.0 mg/dL, respectively) across the three groups. TRACP‐5b and BAP levels decreased by Week 52 regardless of dialysate Ca. Changes in etelcalcetide and concomitant drug doses were generally similar in each group. Conclusion The efficacy and dosing of etelcalcetide with concomitant drugs were essentially unaffected by the dialysate Ca concentration. Patients showed improvements in bone hypermetabolism during treatment. This is a small observational study of the effect of dialysate calcium concentrations on etelcalcetide with concomitant drugs in secondary hyperparathyroidism. No statistically significant differences were found between the different dialysate calcium groups suggesting that calcium concentrations in the dialysate do not modulate the effect of etelcalcetide.
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Affiliation(s)
- Takashi Shigematsu
- Department of Nephrology, Wakayama Medical University, Wakayama-city, Japan
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Isehara-shi, Japan
| | - Keitaro Yokoyama
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Takashi Akiba
- Tokyo Next Nephrology & Dialysis Clinic, Tokyo, Japan
| | - Akifumi Fujii
- Clinical Development Planning, Ono Pharmaceutical Co., Ltd., Osaka-shi, Japan
| | - Atsushi Shinoda
- Medical Affairs, Ono Pharmaceutical Co., Ltd., Osaka-shi, Japan
| | - Tadao Akizawa
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
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Influencia de la concentración de calcio en el líquido de hemodiálisis sobre el control de la tensión arterial. Nefrologia 2019; 39:44-49. [DOI: 10.1016/j.nefro.2018.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Revised: 10/16/2017] [Accepted: 04/04/2018] [Indexed: 11/22/2022] Open
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Yamada S, Ueki K, Tokumoto M, Suehiro T, Kimura H, Taniguchi M, Fujimi S, Kitazono T, Tsuruya K. Effects of Lowering Dialysate Calcium Concentration on Mineral and Bone Disorders in Chronic Hemodialysis Patients: Conversion from 3.0 mEq/L to 2.75 mEq/L. Ther Apher Dial 2015; 20:31-9. [DOI: 10.1111/1744-9987.12329] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Shunsuke Yamada
- Department of Medicine and Clinical Science; Graduate School of Medical Sciences, Kyushu University; Fukuoka Japan
- Department of Internal Medicine; Fukuoka Dental College; Fukuoka Japan
| | - Kenji Ueki
- Department of Medicine and Clinical Science; Graduate School of Medical Sciences, Kyushu University; Fukuoka Japan
| | - Masanori Tokumoto
- Department of Internal Medicine; Fukuoka Dental College; Fukuoka Japan
| | - Takaichi Suehiro
- Department of Medicine and Clinical Science; Graduate School of Medical Sciences, Kyushu University; Fukuoka Japan
| | - Hiroshi Kimura
- Department of Medicine and Clinical Science; Graduate School of Medical Sciences, Kyushu University; Fukuoka Japan
- Fukuoka Renal Clinic; Fukuoka Japan
| | - Masatomo Taniguchi
- Department of Medicine and Clinical Science; Graduate School of Medical Sciences, Kyushu University; Fukuoka Japan
| | | | - Takanari Kitazono
- Department of Medicine and Clinical Science; Graduate School of Medical Sciences, Kyushu University; Fukuoka Japan
| | - Kazuhiko Tsuruya
- Department of Medicine and Clinical Science; Graduate School of Medical Sciences, Kyushu University; Fukuoka Japan
- Department of Integrated Therapy for Chronic Kidney Disease; Graduate School of Medical Sciences, Kyushu University; Fukuoka Japan
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Sakai Y, Otsuka T, Ohno D, Murasawa T, Sakai S, Tsuruoka S. Clinical Benefit of the Change of Dialysate Calcium Concentration From 3.0 to 2.75 mEq/L. Ther Apher Dial 2014; 18:181-4. [DOI: 10.1111/1744-9987.12099] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Yukinao Sakai
- Division of Nephrology; Department of Internal Medicine; Nippon Medical School Musashikosugi Hospital; Kawasaki Japan
| | - Tomoyuki Otsuka
- Division of Nephrology; Department of Internal Medicine; Nippon Medical School Musashikosugi Hospital; Kawasaki Japan
| | - Dai Ohno
- Division of Nephrology; Department of Internal Medicine; Nippon Medical School Musashikosugi Hospital; Kawasaki Japan
| | - Tsuneo Murasawa
- Division of Nephrology; Department of Internal Medicine; Nippon Medical School Musashikosugi Hospital; Kawasaki Japan
| | - Saori Sakai
- Department of Internal Medicine; Zenjinkai Maruko-Clinic; Kawasaki Japan
| | - Shuichi Tsuruoka
- Division of Nephrology; Department of Internal Medicine; Graduate School of Medicine; Nippon Medical School; Tokyo Japan
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GAO ZHUO, LUN LIDE, LI XINLUN. Low calcium dialysate combined with CaCO 3 in hyperphosphatemia in hemodialysis patients. Exp Ther Med 2013; 5:1732-1736. [PMID: 23837063 PMCID: PMC3702715 DOI: 10.3892/etm.2013.1067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 03/20/2013] [Indexed: 01/24/2023] Open
Abstract
This aim of this study was to observe the effects of the application of low calcium dialysate (LCD) combined with oral administration of CaCO3 in the treatment of hyperphosphatemia, as well as blood Ca2+, calcium-phosphate product (CPP), parathyroid hormone (PTH) and blood pressure in patients undergoing hemodialysis. Thirty-one maintenance hemodialysis (MHD) patients with hyperphosphatemia, but normal blood Ca2+, underwent dialysis with an initial dialy-sate Ca2+ concentration (DCa) of 1.50 mmol/l for six months and then with 1.25 mmol/l for six months. The patients who underwent dialysis with a DCa of 1.25 mmol/l were treated orally with 0.3 g CaCO3 tablets three times a day. In the third and sixth months [observation end point (OEP)] of the dialysis, the concentrations of Ca2+, phosphorus and intact PTH (iPTH) were measured; blood pressure and side-effects prior to and following dialysis were also observed. The Ca2+, CPP and iPTH levels increased (P<0.05) in the sixth month of treatment with a DCa of 1.50 mmol/l. However, the Ca2+ concentration declined to a certain degree, CPPs decreased significantly (P<0.05) and the iPTH concentration increased following treatment with a DCa of 1.25 mmol/l for six months. The incidence rate of adverse effects of LCD was 12.9% (4/31); the effects were mainly muscle spasms, hypotension and elevated PTH. The periodic application of LCD combined with the oral administration of CaCO3 effectively reduced serum phosphorus and CPPs among MHD patients with hyperphosphatemia, indicating that the treatment may be used clinically.
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Affiliation(s)
- ZHUO GAO
- Department of Nephrology, Air Force General Hospital, Beijing 100142,
P.R. China
| | - LI-DE LUN
- Department of Nephrology, Air Force General Hospital, Beijing 100142,
P.R. China
| | - XIN-LUN LI
- Department of Nephrology, Air Force General Hospital, Beijing 100142,
P.R. China
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KIATTISUNTHORN KRAIWIPORN, WUTYAM KITTIKARN, INDRANOI ARTIT, VASUVATTAKUL SOMKIAT. Randomized trial comparing pulse calcitriol and alfacalcidol for the treatment of secondary hyperparathyroidism in haemodialysis patients. Nephrology (Carlton) 2011; 16:277-84. [DOI: 10.1111/j.1440-1797.2010.01398.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Spasovski G, Gelev S, Masin-Spasovska J, Selim G, Sikole A, Vanholder R. Improvement of bone and mineral parameters related to adynamic bone disease by diminishing dialysate calcium. Bone 2007; 41:698-703. [PMID: 17643363 DOI: 10.1016/j.bone.2007.06.014] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2007] [Revised: 05/24/2007] [Accepted: 06/20/2007] [Indexed: 11/26/2022]
Abstract
BACKGROUND The existence of adynamic bone disease (ABD) as most prevalent form of renal osteodystrophy in recent years and its reduced ability to handle an exogenous calcium load has implied a higher risk for vascular and soft-tissue calcifications. The effect of low dialysate calcium (LCD) on parathyroid hormone (PTH) secretion in ABD patients has not yet sufficiently been clarified. This randomized, prospective study aimed to compare the effects of LCD and high calcium dialysate (HCD) on the evolution of bone and mineral parameters related to ABD in dialysis patients. METHODS 52 out of 60 patients with predialysis intact PTH<100 pg/ml completed this study and were equally distributed over LCD (1.25 mmol/l) or HCD (1.75 mmol/l) treatment. The duration of the study was 6 months and the only peroral phosphate binder administered was calcium carbonate. Total and ionised calcium were measured monthly in serum before and after dialysis while serum parameters relevant to bone were measured at the enrollment and at 3-month intervals. RESULTS There were no differences in predialysis mean phosphate or calcium x phosphorus product (Ca x P). The most common side effects of both treatments were comparable. Hypotension occurred in 16% and 17% and cramps in 6% and 8% of the dialysis sessions, in the HCD and LCD group, respectively. The groups did not differ in the mean tCa before dialysis, but this parameter was significantly higher in the HCD group vs. LCD at the end of dialysis (2.59+/-0.18 vs. 2.44+/-0.19 mmol/l; p<0.01). The patients of the HCD group also had a significantly higher mean iCa both before (1.08+/-0.05 vs. 1.04+/-0.06 mmol/l; p=0.02) and at the end of dialysis (1.18+/-0.04 vs. 1.48+/-0.04 mmol/l; p<0.01). There were no differences within the LCD group between baseline and end of dialysis treatment values of tCa and iCa. However, the mean tCa and iCa were markedly increased at the end of dialysis in the HDC group [2.40+/-0.21 vs. 2.59+/-0.18 mmol/l (p<0.01); 1.08+/-0.05 vs. 1.18+/-0.04 mmol/l (p<0.01)]. Mean serum levels of iPTH and total alkaline phosphatase in the LCD group were increased at 3 months and at the end of the study compared with the baseline levels [(38.6+/-22.9 vs. 63.3+/-46.0 vs. 78.6+/-44.7 pg/ml); (59.5+/-18.7 vs. 75.9+/-26.7 vs. 84.0+/-35.4 U/l)], respectively, and bone alkaline phosphatase increased also only after 6 months of treatment (23.4+/-7.3 U/l vs. 35.6+/-22.3). The bone markers in the HCD group did not change. At the end of the study all bone parameters in the LCD group were significantly higher than in the HCD group. CONCLUSION There was an evolution towards parameters reflecting higher bone turnover in patients treated with dialysate calcium of 1.25 mmol/l, probably by prevention of a positive calcium balance and enabling sustained stimulation of PTH secretion. Hence, LCD might be considered a valuable therapeutic option for ABD patients.
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Affiliation(s)
- Goce Spasovski
- Department of Nephrology, Clinical Center Skopje, University of Skopje, Vodnjanska 17, 1000 Skopje, Macedonia.
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Lezaic V, Pejanovic S, Kostic S, Pljesa S, Dimkovic N, Komadina L, Jovanovic D, Marinkovic J, Djukanovic L. Effects of Lowering Dialysate Calcium Concentration on Mineral Metabolism and Parathyroid Hormone Secretion: A Multicentric Study. Ther Apher Dial 2007; 11:121-30. [PMID: 17381533 DOI: 10.1111/j.1744-9987.2007.00419.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
This prospective study was conducted with the aim of examining the efficacy of lowering dialysate calcium (dCa) in order to: (i) stimulate bone turnover in hemodialysis patients with biochemical signs of adynamic bone disease (ABD) (hypercalcemia, normal alkaline phosphatase and intact parathyroid hormone (iPTH) <150 pg/mL); and (ii) diminish hypercalcemia in patients with secondary hyperparathyroidism (sHPT) (hypercalcemia, high alkaline phosphatase and iPTH > 400 pg/mL), thus permitting the use of calcium-containing phosphorus binders and vitamin D metabolites. Patients were divided into: an ABD-treated group (24 patients), a sHPT-treated group (18 patients), an ABD-control group (12 patients) and a sHPT-control group (11 patients). For the ABD- and sHPT-treated patients, hemodialysis was conducted with dCa 1.5 mmol/L for three months and then with dCa 1.25 mmol/L for an additional three months, while in the control groups hemodialysis was conducted with dCa 1.75 mmol/L during the entire study. Reduction of dCa in patients with ABD caused a slight but insignificant decrease of Ca, but a significant and permanent increase of bone-specific alkaline phosphatase and intact parathyroid hormone level serum levels. Reduction of dCa in patients with sHPT slightly but insignificantly decreased Ca and intact parathyroid hormone level values. Nevertheless, this enabled the calcium-based phosphate binder dose to be raised and vitamin D3 metabolites to be introduced. Logistic regression analysis indicated that milder bone disease (both ABD and sHPT) was associated with more the favorable effect of dCa reduction. Thus, low dCa stimulated parathyroid glands and increased bone turnover in ABD patients, and enabled better control of mineral metabolism in sHPT patients.
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Affiliation(s)
- Visnja Lezaic
- University Clinical Center, Institute of Urology and Nephrology, Department of Nephrology, KC Serbia.
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Yokoyama K, Yoshida H, Kato J, IIda R, Kawamura Y, Yamamoto H, Hosoya T. The low-calcium concentration of dialysate induced markedly an increase of serum parathyroid hormone in a continuous ambulatory peritoneal dialysis patient. Kidney Int 2007. [DOI: 10.1038/sj.ki.5002062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Haris A, Sherrard DJ, Hercz G. Response to ‘The low-calcium concentration of dialysate induced a marked increase of serum parathyroid hormone level in a continuous ambulatory peritoneal dialysis patient’. Kidney Int 2007; 71:594-5. [PMID: 17344898 DOI: 10.1038/sj.ki.5002070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Taji Y, Morimoto T, Fukuhara S, Fukui T, Kuwahara T. Effects of low dialysate calcium concentration on health-related quality of life in hemodialysis patients. Clin Exp Nephrol 2005; 9:153-7. [PMID: 15980951 DOI: 10.1007/s10157-005-0350-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2004] [Accepted: 03/04/2005] [Indexed: 11/28/2022]
Abstract
BACKGROUND A dialysate calcium concentration of 2.5 meq/l (1.25 mmol/l) is currently recommended, but there are not enough studies to examine the effects of this calcium concentration on clinical outcomes. We explored the effects of this calcium concentration on health-related quality of life (HRQOL) in hemodialysis patients. METHODS The dialysate calcium concentration was lowered from 3.0 meq/l to 2.5 meq/l in 78 hemodialysis patients. The Medical Outcomes Study (MOS) Short Form 36 (SF-36) norm-based scores, the doses of recombinant human erythropoietin (rHuEpo), and the serum levels of corrected calcium, phosphorus, intact parathyroid hormone (i-PTH), and hemoglobin were compared at baseline and 8 months after the change of dialysate calcium concentration. RESULTS Seventy-three patients completed the study. Mean changes in SF-36 scores were: physical functioning, -2.4; role physical, -3.9; bodily pain, -3.4; general health perception, -1.5; vitality, -2.2; social functioning, -1.9; role emotional, -2.0; mental health, -2.0. The declines of scores for role physical and bodily pain were significant. Serum i-PTH levels increased significantly, from 212 pg/ml to 278 pg/ml, while the doses of rHuEpo and serum levels of corrected calcium, phosphorus, and hemoglobin did not change significantly. CONCLUSIONS A dialysate calcium concentration of 2.5 meq/l was not shown to have positive effects on HRQOL.
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Affiliation(s)
- Yoshinori Taji
- Department of Nephrology, Saiseikai Nakatsu Hospital, Osaka, Japan.
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Levin NW, Gotch FA, Kuhlmann MK. Factors for increased morbidity and mortality in uremia: hyperphosphatemia. Semin Nephrol 2005; 24:396-400. [PMID: 15490397 DOI: 10.1016/j.semnephrol.2004.06.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Hyperphosphatemia is a metabolic abnormality present in the majority of patients treated by dialysis. Inorganic phosphorus (iP) can be categorized as a true uremic toxin given its known in vivo and in vitro effects and the ability to reduce these effects by normalizing iP levels. However, despite regular and adequate dialysis treatment, the goal of normalization of phosphorus levels rarely is achieved. This article briefly evaluates the significance of hyperphosphatemia in hemodialysis patients, current therapeutic approaches, and describes a new model for evaluating the dialysis prescription for iP balance.
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Abstract
There is growing evidence that not only serum calcium concentration but also excess calcium load is associated with vascular calcification and mortality in hemodialysis patients. Calcium load in hemodialysis patients cumulatively comes from three different routes: oral intake of calcium including calcium-based phosphate binders, traffic of calcium from/to dialysate, and calcemic action of vitamin D. The K/DOQI guidelines recommend sevelamer hydrochloride instead of calcium-containing phosphate binders to control serum phosphate concentration. However, in Japan, both kinds of phosphate binders are used concomitantly, mainly because Japanese patients are prone to a higher incidence of sevelamer-associated adverse events such as gastrointestinal symptoms. Regarding the calcium concentration of dialysate (D-Ca) in Japan, 3.0 mEq/L is more popular than 2.5 mEq/L. Calcium loaded through 3.0 mEq/L dialysate may lead to metastatic calcification rather than to bone formation because serum phosphate concentration rebounds several hours after the end of each hemodialysis session when plasma pH is still high. In contrast, use of 2.5 mEq/L dialysate may result in an unfavorable increase of intact parathyroid hormone particularly when the amount of oral calcium intake is reduced. Although a higher dose of vitamin D is required to counteract the stimulation of parathyroid glands, hypercalcemia is less likely with 2.5 mEq/L dialysate. As the new K/DOQI guidelines are released, it is time to discuss the appropriate D-Ca as well as doses and kinds of phosphate binders and vitamin D for the comprehensive management of Japanese hemodialysis patients.
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Affiliation(s)
- Takayuki Hamano
- Department of Internal Medicine and Therapeutics, Osaka University School of Medicine, Suita, Osaka 565-0871, Japan
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