Pharmacological Management of Secondary Hyperparathyroidism in Patients with Chronic Kidney Disease

Secondary hyperparathyroidism (SHPT) is a common complication of chronic kidney disease (CKD) and is part of the CKD-mineral bone disorder (CKD-MBD). SHPT is associated with increased risk of fracture and mortality; thus, SHPT control is recommended as kidney function declines. Effective SHPT management becomes more difficult once skeletal and cardiovascular adverse effects associated with severe SHPT have become established. However, interventional studies to lower parathyroid hormone (PTH) have so far shown inconsistent results in improving patient-centred outcomes such as mortality, cardiovascular events and fracture. Pharmacological treatment effect on PTH level is also inconsistent between pre-dialysis CKD and dialysis patients, which adds to the complexity of SHPT management. This review aims to give an overview on the pathophysiology, pharmacological and non-pharmacological treatment for SHPT in CKD including some of the limitations of current therapeutic options.

Effects and safety of calcimimetics in end stage renal disease patients with secondary hyperparathyroidism: a meta-analysis

Purpose

Secondary hyperparathyroidism (SHPT) is one of the most common abnormalities of mineral metabolism in patients with chronic kidney disease. We performed a meta-analysis to determine the effect and safety of cinacalcet in SHPT patients receiving dialysis.

Methods

The meta-analysis was performed to determine the effect and safety of cinacalcet in SHPT patients receiving dialysis by using the search terms ‘cinacalcet’ or ‘mimpara’ or ‘sensipar’ or ‘calcimimetic’ or ‘R586’ on MEDLINE and EMBASE (January 1990 to February 2012).

Results

Fifteen trials were included, all of which were performed between 2000 and 2011 enrolling a total of 3387 dialysis patients. Our study showed that calcimimetic agents effectively ameliorated iPTH levels(WMD, −294.36 pg/mL; 95% CI, −322.76 to −265.95, P<0.001) in SHPT patients and reduced serum calcium (WMD, −0.81 mg/dL; 95% CI, −0.89 to −0.72, P<0.001) and phosphorus disturbances(WMD, −0.29 mg/dL; 95% CI, −0.41 to −0.17, P<0.001). The percentage of patients in whom there was a 30% decrease in serum iPTH levels by the end of the dosing was higher in cinacalcet group than that in control group(OR = 10.75, 95% CI: 6.65–17.37, P<0.001). However, no significant difference was found in all-cause mortality and all adverse events between calcimimetics and control groups(OR = 0.86, 95% CI: 0.46–1.60, P = 0.630; OR = 1.30, 95% CI: 0.78–2.18, P = 0.320, respectively). Compared with the control therapy, there was a significant increase in the episodes of hypocalcemia (OR = 2.46, 95% CI: 1.58–3.82, P<0.001), nausea (OR = 2.45, 95% CI: 1.29–4.66, P = 0.006), vomiting(OR = 2.78, 95% CI: 2.14–3.62, P<0.001), diarrhea(OR = 1.51, 95% CI: 1.04–2.20, P = 0.030) and upper respiratory tract infection (OR = 1.79, 95% CI: 1.20–2.66, P = 0.004)in calcimimetics group.

Conclusions

Calcimimetic treatment effectively improved biochemical parameters of SHPT patients receiving dialysis without increasing all-cause mortality and all adverse events.

[Cinacalcet treatment for secondary hyperparathyroidism in dialysis patients in real-world clinical practice - the ECHO observational study: French experience]

In chronic kidney disease patients with secondary hyperparathyroidism (SHPT), the recommended K/DOQI™ target serum levels of parathyroid hormone (PTH), calcium (Ca) and phosphorus (P) are difficult to reach and maintain stable. We present the results of the French cohort from the European study ECHO which investigated the use and effectiveness of cinacalcet in real-world clinical practice.

METHODS

An observational study of the SHPT management in dialysis patients, partially retrospective (from 6 months prior to cinacalcet initiation) and partially prospective (up to 12 months of cinacalcet treatment).

RESULTS

Four hundred and eighty-five French patients were enrolled from 44 centres. Cinacalcet was given in combination with active vitamin D treatment (39%) and phosphate binders (87%). After 12 months, the proportion of patients reaching recommended K/DOQI™ target levels had increased from 2.5% to 28.8% for PTH, from 46.8% to 50.1% for Ca, from 40.0% to 49.9% for P and 54.8% to 77.7% for the CaxP product. The proportions of patients using active vitamin D and sevelamer decreased by 6% and 20% respectively. Adverse events were reported in 37 (7.6%) patients, mainly nausea (2.1%), vomiting (2.1%) and dyspepsia (1.2%).

CONCLUSIONS

The results of this study are consistent with data from controlled and randomized studies showing that cinacalcet increases the proportion of patients achieving the K/DOQI™ targets for PTH, Ca, P and CaxP in real-world clinical practice.

Prescription patterns and mineral metabolism abnormalities in the cinacalcet era: results from the MBD-5D study

BACKGROUND AND OBJECTIVES

Prescription patterns for hemodialysis patients with secondary hyperparathyroidism have varied widely since market introduction of cinacalcet. This study examined associations between prescription patterns and subsequent laboratory values.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Using a Mineral and Bone Disorder Outcomes Study for Japanese CKD Stage 5D Patients subcohort, 1716 prevalent hemodialysis patients (4048 sets for repeated measures between January 2008 and July 2009) with an intact parathyroid hormone (iPTH) level >180 pg/ml who used intravenous vitamin D receptor activator (VDRA) without cinacalcet were selected. Prescription patterns were defined based on cinacalcet administration (starting or not) and VDRA dosage change (decreased [<-25%], stable [-25% to 25%], or increased [>25%]). Proportion differences (PDs) were determined for decreasing iPTH levels by at least one category (<180, 180-299, 300-499, and ≥500 pg/ml) and for achieving target phosphorus (3.5-6.0 mg/dl) and calcium (8.4-10.0 mg/dl) levels, adjusting for potential confounders.

RESULTS

The starting cinacalcet and increased VDRA patterns were associated with decreasing iPTH levels (PD, 0.25 and 0.13; 95% confidence intervals [95% CIs], 0.19-0.31 and 0.09-0.17, respectively); combination use had an additive association (PD, 0.34; 95% CI, 0.20-0.42). The starting cinacalcet and decreased VDRA combination was associated with simultaneously achieving target phosphorus (PD, 0.12; 95% CI: 0.04-0.20) and calcium (PD, 0.09; 95% CI, 0.01-0.17) levels.

CONCLUSIONS

Certain combinations of cinacalcet and VDRA were associated with decreasing iPTH and achieving targets for phosphorus and calcium. Combinations may prove advantageous versus VDRA alone in managing secondary hyperparathyroidism.