NDT Advance Access originally published online on July 10, 2007
Nephrology Dialysis Transplantation 2007 22(10):3087-3088; doi:10.1093/ndt/gfm425
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Reply
Email: ArenasD{at}perpetuosocorro.nehos.comSir,
We are grateful to Cozzolino et al. for their comments on our study ‘Implementation of "K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease" after the introduction of cinacalcet in a population of patients on chronic haemodialysis’. Our study showed the good results of the combined use of cinacalcet and low doses of vitamin D metabolites in a subgroup of patients with severe secondary hyperparathyroidism, that was not controlled with vitamin D alone, and that had inadequate elevations in serum calcium and/or phosphorus.
First of all, we would like to clarify the apparent inconsistencies in the levels of serum PTH, calcium, phosphorus and calcium–phosphate product between the text and the table. These results are different because they referred to different periods in the study. The values in the text are the mean of all PTH, calcium and phosphorus measurements obtained during the whole period of 9 months, before (PTH 590.4 pg/ml) and 9 months after the treatment with cinacalcet (PTH 414.2 pg/ml). In the Table, the PTH, calcium and phosphorus at time 0 (just before starting cinacalcet) and after 9 months of treatment with cinacalcet are shown.
Control of secondary hyperparathyroidism (SHPT) in CKD patients is frequently difficult [1,2] and it has important implications for patient morbidity and mortality [3,4]. Fortunately, in recent years, there have been important advances with the appearence of new drugs which represent a clear benefit in the treatment of this problem. The ability of cinacalcet to reduce PTH secretion, along with reductions in the serum calcium, phosphorus and calcium–phosphorus product, provides an alternative to the traditional treatment paradigm, and should be an addition to our therapeutic strategy in the management of SHPT. In addition to its effects on PTH and mineral metabolism, cinacalcet has demonstrated favourable effects on important clinical outcomes: combined results from four clinical trials (cinacalcet randomization) led to significant reductions in the risk of parathyroidectomy, fractures and cardiovascular hospitalization, along with improvements in self-reported physical function and diminished pain [5]. On the other hand, the pleiotropic effects of vitamin D have recently been highlighted; vitamin D regulates cell proliferation and differentiation, modulates the immune system, and is involved in several endocrine systems. Vitamin D metabolites therapy provides survival benefits and, certainly, paricalcitol has demonstrated good results in terms of PTH, calcium and phosphorus control, as well as a reduced mortality risk when comparing treated and untreated patients [6].
The optimal treatment for SHPT in HD patients is yet to be established. It is possible that the combined use of both drugs (cinacalcet and paricalcitol) might offer some therapeutical advantages: we should further investigate the use of these drugs (either alone or in combination) in different patient populations and see the outcomes in terms of mortality, morbidity and costs, in order to establish the most efficient treatment in each situation.
Fernando Álvarez-ude
Hospital Perpetuo Socorro.
Plaza Dr Gomez Ulla, 15, 03013
Alicante
References
- Arenas MD, Alvarez-Ude F, Gil MT, et al. Application of NKF-K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease: changes of clinical practices and their effects on outcomes and quality standards in three haemodialysis units. Nephrol Dial Transplant (2006) 21:1663–1668.
[Abstract/Free Full Text] - Wei M, Taskapan H, Esbaei K, Jassal SV, Bargman JM, Oreopoulos DG. K/DOQI guideline requirements for calcium, phosphate, calcium phosphate product, and parathyroid hormone control in dialysis patients: can we achieve them? Int Urol Nephrol (2006) 38:739–743.[CrossRef][Web of Science][Medline]
- Block GA, Martin KJ, de Francisco AL, et al. Cinacalcet for secondary hyperparathyroidism in patients receiving hemodialysis. N Engl J Med (2004) 350:1516–1525.
[Abstract/Free Full Text] - Young EW, Akiba T, Albert JM, et al. Magnitude and impact of abnormal mineral metabolism in hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis (2004) 44(5 Suppl 2):34–38.[CrossRef][Medline]
- Cunningham J, Danese M, Olson K, Klassen P, Chertow GM. Effects of the calcimimetic cinacalcet HCl on cardiovascular disease, fracture, and health-related quality of life in secondary hyperparathyroidism. Kidney Int (2005) 68:1793–1800.[CrossRef][Web of Science][Medline]
- Kalantar_Zadeh K, Kuwae N, Regidor DL, et al. Survival predictability of time-varying indicators of bone disease in maintenance hemodialysis patients. Kidney Int (2006) 70:771–780.[CrossRef][Web of Science][Medline]
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