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Eddington H, Chinnadurai R, Alderson H, Ibrahim ST, Chrysochou C, Green D, Erekosima I, Hutchison A, Bubtana A, Hegarty J, Kalra PA. A randomised controlled trial to examine the effects of cinacalcet on bone and cardiovascular parameters in haemodialysis patients with advanced secondary hyperparathyroidism. BMC Nephrol 2021; 22:106. [PMID: 33757437 PMCID: PMC7989372 DOI: 10.1186/s12882-021-02312-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 03/18/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Secondary hyperparathyroidism may lead to increased cardiovascular risk. The use of cinacalcet may improve bone and cardiovascular health with improved parathormone (PTH) and phosphate control. METHODS This is an open-label prospective randomised controlled trial to compare progression of cardiovascular and chronic kidney disease mineral and bone disorder (CKD-MBD) parameters. Patients were randomised to receive cinacalcet alongside standard therapy or standard therapy alone. Thirty-six haemodialysis patients who had > 90 days on dialysis, iPTH > 300 pg/mL, calcium > 2.1 mmol/L and age 18-75 years were included. Following randomization, all 36 patients underwent an intensive 12-week period of bone disease management aiming for iPTH 150-300 pg/mL. The primary outcome was change in vascular calcification using CT agatston score. Secondary outcomes included pulse wave velocity (PWV), left ventricular mass index (LVMI), carotid intima-media thickness (CIMT), augmentation index (Aix) and bone measurements. The above measurements were obtained at baseline and 12 months. RESULTS There was no evidence of a group difference in the progression of calcification (median change (IQR) cinacalcet: 488 (0 to1539); standard therapy: 563 (50 to 1214)). In a post hoc analysis combining groups there was a mean (SD) phosphate reduction of 0.3 mmol/L (0.7) and median (IQR) iPTH reduction of 380 pg/mL (- 754, 120). Regression of LVMI and CIMT was seen (P = 0.03 and P = 0.001) and was significantly associated with change of phosphate on multi-factorial analyses. CONCLUSIONS With a policy of intense CKD-MBD parameter control, no significant benefit in bone and cardiovascular markers was seen with the addition of cinacalcet to standard therapy over one year. Tight control of hyperphosphataemia and secondary hyperparathyroidism may lead to a reduction in LVMI and CIMT but this needs further investigation. Although the sample size was small, meticulous trial supervision resulted in very few protocol deviations with therapy.
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Affiliation(s)
- Helen Eddington
- Renal Department, University Hospitals of Birmingham NHS Trust, Birmingham, UK
| | - Rajkumar Chinnadurai
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, M6 8HD, UK. .,Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
| | - Helen Alderson
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, M6 8HD, UK
| | - Sara T Ibrahim
- Department of Internal Medicine and Nephrology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | | | - Darren Green
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, M6 8HD, UK
| | - Ibi Erekosima
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, M6 8HD, UK
| | | | - Abdalla Bubtana
- Department of Renal Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - Janet Hegarty
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, M6 8HD, UK
| | - Philip A Kalra
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, M6 8HD, UK.,Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Lozano-Ortega G, Waser N, Bensink ME, Goring S, Bennett H, Block GA, Chertow GM, Trotman ML, Cooper K, Levy AR, Belozeroff V. Effects of calcimimetics on long-term outcomes in dialysis patients: literature review and Bayesian meta-analysis. J Comp Eff Res 2018; 7:693-707. [DOI: 10.2217/cer-2018-0015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Aim: Randomized controlled trials (RCTs) with clinical outcomes are considered the gold standard for regulatory approval. However, by design they are only able to answer a small number of clinical questions. Other high-quality studies are required for clinical decision-making. The EVOLVE was the largest RCT, evaluating the effects of cinacalcet on clinical outcomes among adult patients receiving maintenance dialysis suffering from secondary hyperparathyroidism. While the EVOLVE trial did not reach its primary end point, imbalance in subjects’ age at randomization and discontinuation rates are two of the reasons that the lack of mortality benefit is in question. We undertook a systematic literature review and Bayesian meta-analysis combining randomized and observational studies on the estimated effects of the oral calcimimetic cinacalcet on clinical outcomes including all-cause mortality, cardiovascular-related mortality, hospitalization for cardiovascular events, fracture and parathyroidectomy among patients on maintenance dialysis. Methods: Data sources included MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials databases. RCTs and observational studies were included. Data extraction was completed by two authors independently and in duplicate determined the methodological quality of the studies and extracted data. Results: Of 564 unique citations identified, 16 studies were included: six observational studies and ten RCTs. Four high-quality studies (two observational and two RCTs) were deemed suitable for meta-analysis. Results indicated a statistically significant reduction in the risk of death associated with cinacalcet (hazard ratio: 0.83; 95% credible interval: 0.78–0.89).Conclusion: The results of this meta-analysis indicate that treatment of secondary hyperparathyroidism with calcimimetic therapy may in fact reduce mortality among patients receiving maintenance dialysis. This finding provides justification for a well-designed and adequately powered randomized trial to definitively address the question.
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Affiliation(s)
| | | | - Mark E Bensink
- Departments of Global Health Economics (MB, VB), Biostatistics (MLT), and Global Medical (KC), Amgen Inc., One Amgen Center Drive, Thousand Oaks, CA 9132, USA
| | - Sarah Goring
- ICON plc, Epidemiology, Vancouver, BC V6B 1P1, Canada
| | | | - Geoffrey A Block
- Denver Nephrology, 130 Rampart Way, Suite 300b, Denver, CO 80230, USA
| | - Glenn M Chertow
- Stanford University, School of Medicine, 1070 Arastradero Rd, Ste 313, Palo Alto, CA 94034, USA
| | - Marie-Louise Trotman
- Departments of Global Health Economics (MB, VB), Biostatistics (MLT), and Global Medical (KC), Amgen Inc., One Amgen Center Drive, Thousand Oaks, CA 9132, USA
| | - Kerry Cooper
- Departments of Global Health Economics (MB, VB), Biostatistics (MLT), and Global Medical (KC), Amgen Inc., One Amgen Center Drive, Thousand Oaks, CA 9132, USA
| | - Adrian R Levy
- Dalhousie University Department of Community Health and Epidemiology, Halifax, NS B3H 1V7, Canada
| | - Vasily Belozeroff
- Departments of Global Health Economics (MB, VB), Biostatistics (MLT), and Global Medical (KC), Amgen Inc., One Amgen Center Drive, Thousand Oaks, CA 9132, USA
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Sin HY. Prospective cohort study: Cinacalcet-mediated lowering of PTH level and cardiovascular disease mortality in younger Korean patients with stage 5 CKD at a Korean secondary hospital. J Clin Pharm Ther 2017; 42:607-614. [PMID: 28585333 DOI: 10.1111/jcpt.12565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 04/25/2017] [Indexed: 11/28/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVES Cinacalcet may reduce cardiovascular disease (CVD) mortality in elderly patients with chronic kidney disease (CKD). However, previous studies of the clinical responses to cinacalcet have exhibited discrepancies due to highly variable baseline levels of parathyroid hormone (PTH), kidney function and age. Little is known about the true effect of cinacalcet on stage 5 CKD. The objective of the current observational study was to evaluate whether cinacalcet-mediated lowering of PTH levels improves all-cause mortality and cardiovascular disease mortality in younger stage 5 CKD patients (mean age <55 years). METHODS This prospective, cohort study reviewed the electronic medical records (EMRs) of CKD patients (n=540) with secondary hyperparathyroidism (SHPT) for a period of 36 months. Of 540 patients, 104 subjects met the inclusion criteria and were included in the final evaluation (mean serum iPTH 688.7 pg/mL). Patients were divided into a cinacalcet group (n=43) and a non-cinacalcet group (n=61). RESULTS AND DISCUSSION Comparing the cinacalcet group to the non-cinacalcet group, Cox proportional hazard modelling found that all-cause mortality was five (31.3%) in the cinacalcet group and three (15.8%) in the non-cinacalcet group for patients with serum levels of PTH>600 pg/mL [P=.277, hazard ratio 2.213, 95% confidence interval (CI): 0.529-9.262]. Cardiovascular disease mortality (CVD: heart disease) occurred in two (5.3%) in the cinacalcet group and one (2.1%) in the non-cinacalcet group [P=.425, HR 2.611, 95% CI: 0.228-9.939]. Overall, there were no significant differences in CVD mortality between the two groups. WHAT IS NEW AND CONCLUSION Cinacalcet was not associated with decreases in all-cause mortality or CVD mortality in younger stage 5 CKD patients with high PTH levels (>600 pg/mL). This could be explained by the diversity of the population in terms of the patient's age, health insurance policies, target serum level of biochemical and PTH, and glomerular filtration rate (GFR) at admission. These data, although based on an observational study, indicate that adding cinacalcet to the current standard care for younger stage 5 CKD patients should be re-evaluated.
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Affiliation(s)
- H Y Sin
- College of Pharmacy, Duksung Women's University, Seoul, Korea
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