1
|
Bernardor J, De Mul A, Bacchetta J, Schmitt CP. Impact of Cinacalcet and Etelcalcetide on Bone Mineral and Cardiovascular Disease in Dialysis Patients. Curr Osteoporos Rep 2023; 21:193-204. [PMID: 36848027 DOI: 10.1007/s11914-023-00782-x] [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] [Accepted: 02/15/2023] [Indexed: 03/01/2023]
Abstract
PURPOSES OF REVIEW With chronic kidney disease (CKD) progression, secondary hyperparathyroidism (sHPT) and mineral and bone metabolism disease (MBD) almost inevitably develop and result in renal osteodystrophy and cardiovascular disease (CVD). Together with active vitamin D, calcimimetics are the main therapy for sHPT in CKD. This review provides an overview of the therapeutic effects of oral cinacalcet and intravenous etelcalcetide on CKD-MBD and vascular disease, with a focus on pediatric dialysis patients. RECENT FINDINGS Randomized controlled trials in adults and children demonstrate efficient lowering of parathyroid hormone (PTH) by the calcimimetics together with a reduction in serum calcium and phosphate when combined with low-dose active vitamin D, while therapy with active vitamin D analogs alone increases serum calcium and phosphate. Cinacalcet and etelcalcetide both improve bone formation and correct adynamic bone, i.e., have a direct bone anabolic effect. They decrease serum calciprotein particles, which are involved in endothelial dysfunction, atherogenesis, and vascular calcification. Clinical trials in adults suggest a modest slowing of the progression of cardiovascular calcification with cinacalcet. Calcimimetic agents represent a major pharmacological tool for improved control of CKD-MBD, by efficiently counteracting sHPT and allowing for better control of calcium/phosphate and bone homeostasis. Albeit definite evidence is lacking, the beneficial effects of calcimimetics on CVD are promising. Routine use of cinacalcet has been suggested in children.
Collapse
Affiliation(s)
- Julie Bernardor
- UMR 1033, Faculté de Médecine Lyon Est, INSERM, Université Claude Bernard Lyon1, Lyon, France.
- Centre de Référence Des Maladies Rares du Calcium Et du Phosphate, Filière Maladies Rares OSCAR, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France.
- Centre de Référence Des Maladies Rénales Rares, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Filières Maladies Rares ORKID Et ERK-Net, Bron, France.
- Faculté de Médecine, Université de Nice Côte d'Azur, Nice, France.
- Unité d'hémodialyse Pédiatrique, CHU de Nice, Archet 2, 06202, Nice, France.
| | - Aurélie De Mul
- Centre de Référence Des Maladies Rares du Calcium Et du Phosphate, Filière Maladies Rares OSCAR, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
- Centre de Référence Des Maladies Rénales Rares, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Filières Maladies Rares ORKID Et ERK-Net, Bron, France
- Pediatric Nephrology Unit, Geneva University Hospital, Geneva, Switzerland
| | - Justine Bacchetta
- UMR 1033, Faculté de Médecine Lyon Est, INSERM, Université Claude Bernard Lyon1, Lyon, France
- Centre de Référence Des Maladies Rares du Calcium Et du Phosphate, Filière Maladies Rares OSCAR, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
- Centre de Référence Des Maladies Rénales Rares, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Filières Maladies Rares ORKID Et ERK-Net, Bron, France
- Faculté de Médecine Lyon Est, Université Claude Bernard, Lyon 1, Lyon, France
| | - Claus Peter Schmitt
- Department of Pediatrics I, University Children's Hospital, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| |
Collapse
|
2
|
Hernandes FR, Goldenstein P, Custódio MR. Treatment of Hyperparathyroidism (SHPT). J Bras Nefrol 2021; 43:645-649. [PMID: 34910799 PMCID: PMC8823921 DOI: 10.1590/2175-8239-jbn-2021-s107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 07/01/2021] [Indexed: 11/21/2022] Open
|
3
|
Randomized Controlled Trials 7: On Contamination and Estimating the Actual Treatment Effect. Methods Mol Biol 2021. [PMID: 33871851 DOI: 10.1007/978-1-0716-1138-8_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
Abstract
The intention-to-treat analysis is the gold standard for evaluating the efficacy in a randomized controlled trial. However, when non-adherence to randomized treatments is high the actual treatment effect may be underestimated. The impact of drop-out from the intervention group or drop-in to the control group may be controlled by trial design, increasing the sample size, effective study execution, and a pre-specified analytical plan to take contamination into account.These analyses may include censoring at the time of co-interventions associated with stopping treatment, lag censoring which allows an additional period after discontinuation of study treatment to account for residual treatment effects, inverse probability of censoring weights (IPCW), accelerated failure time models, and contamination adjusted intent-to-treat analysis . These methods are particularly useful in assessing the "prescribed efficacy" of the study treatment, which can aid clinical decision-making .
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Block GA, Chertow GM, Cooper K, Xing S, Fouqueray B, Halperin M, Danese MD. Fibroblast growth factor 23 as a risk factor for cardiovascular events and mortality in patients in the EVOLVE trial. Hemodial Int 2020; 25:78-85. [PMID: 33016505 DOI: 10.1111/hdi.12887] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 09/17/2020] [Accepted: 09/18/2020] [Indexed: 01/10/2023]
Abstract
INTRODUCTION High mortality rates in patients with chronic kidney disease-mineral and bone disorder (CKD-MBD) receiving maintenance hemodialysis are largely due to cardiovascular (CV) events. METHODS We evaluated associations between MBD parameters, fibroblast growth factor 23 (FGF23) concentrations, and clinically adjudicated CV events from the Evaluation of Cinacalcet Hydrochloride Therapy to Lower Cardiovascular Events (EVOLVE) trial. Patients enrolled in EVOLVE, who had not experienced any study endpoints between randomization and week 20 with evaluable baseline and week 20 values for key laboratory parameters (parathyroid hormone, calcium, phosphate, and FGF23), were assessed. We used adjusted Cox proportional hazards regression models to estimate relative risk of outcomes (primary composite, all-cause mortality, and CV events) based on FGF23 and MBD parameters. Laboratory values were modeled with linear terms and using natural cubic splines with two degrees of freedom. FINDINGS For the primary endpoint, patients assessed (N = 2309) were followed up over a mean duration of 3.1 years, during which 1037 CV events (497 deaths, 540 nonfatal events) occurred. Adjusted models showed an association between FGF23 and the risk of CV events. Hazard ratio per log unit of FGF23 at week 20 was 1.09 [95% CI: 1.03-1.16], and the hazard ratio per log unit change in FGF23 from week 0 to week 20 was 1.09 [95% CI: 1.00-1.17]. DISCUSSION Our data highlight FGF23 as an independent CV risk factor and potential biomarker and therapeutic target for patients with CKD-MBD receiving maintenance hemodialysis.
Collapse
Affiliation(s)
| | - Glenn M Chertow
- Stanford University School of Medicine, Palo Alto, California, USA
| | | | - Shan Xing
- Amgen Inc., Thousand Oaks, California, USA
| | | | - Marc Halperin
- Outcomes Insights, Inc., Agoura Hills, California, USA
| | - Mark D Danese
- Outcomes Insights, Inc., Agoura Hills, California, USA
| |
Collapse
|
6
|
Jäger E, Murthy S, Schmidt C, Hahn M, Strobel S, Peters A, Stäubert C, Sungur P, Venus T, Geisler M, Radusheva V, Raps S, Rothe K, Scholz R, Jung S, Wagner S, Pierer M, Seifert O, Chang W, Estrela-Lopis I, Raulien N, Krohn K, Sträter N, Hoeppener S, Schöneberg T, Rossol M, Wagner U. Calcium-sensing receptor-mediated NLRP3 inflammasome response to calciprotein particles drives inflammation in rheumatoid arthritis. Nat Commun 2020; 11:4243. [PMID: 32843625 PMCID: PMC7447633 DOI: 10.1038/s41467-020-17749-6] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 07/16/2020] [Indexed: 12/17/2022] Open
Abstract
Increased extracellular Ca2+ concentrations ([Ca2+]ex) trigger activation of the NLRP3 inflammasome in monocytes through calcium-sensing receptor (CaSR). To prevent extraosseous calcification in vivo, the serum protein fetuin-A stabilizes calcium and phosphate into 70-100 nm-sized colloidal calciprotein particles (CPPs). Here we show that monocytes engulf CPPs via macropinocytosis, and this process is strictly dependent on CaSR signaling triggered by increases in [Ca2+]ex. Enhanced macropinocytosis of CPPs results in increased lysosomal activity, NLRP3 inflammasome activation, and IL-1β release. Monocytes in the context of rheumatoid arthritis (RA) exhibit increased CPP uptake and IL-1β release in response to CaSR signaling. CaSR expression in these monocytes and local [Ca2+] in afflicted joints are increased, probably contributing to this enhanced response. We propose that CaSR-mediated NLRP3 inflammasome activation contributes to inflammatory arthritis and systemic inflammation not only in RA, but possibly also in other inflammatory conditions. Inhibition of CaSR-mediated CPP uptake might be a therapeutic approach to treating RA.
Collapse
Affiliation(s)
- Elisabeth Jäger
- Department of Internal Medicine, Division of Rheumatology, Leipzig University, Liebigstraße 19, 04103, Leipzig, Germany
| | - Supriya Murthy
- Department of Internal Medicine, Division of Rheumatology, Leipzig University, Liebigstraße 19, 04103, Leipzig, Germany
| | - Caroline Schmidt
- Department of Internal Medicine, Division of Rheumatology, Leipzig University, Liebigstraße 19, 04103, Leipzig, Germany
| | - Magdalena Hahn
- Department of Internal Medicine, Division of Rheumatology, Leipzig University, Liebigstraße 19, 04103, Leipzig, Germany
| | - Sarah Strobel
- Department of Internal Medicine, Division of Rheumatology, Leipzig University, Liebigstraße 19, 04103, Leipzig, Germany
| | - Anna Peters
- Rudolf Schönheimer Institute of Biochemistry, Faculty of Medicine, Leipzig University, Johannisallee 30, 04103, Leipzig, Germany
| | - Claudia Stäubert
- Rudolf Schönheimer Institute of Biochemistry, Faculty of Medicine, Leipzig University, Johannisallee 30, 04103, Leipzig, Germany
| | - Pelin Sungur
- Jena Center for Soft Matter (JCSM), Friedrich-Schiller-University Jena, Humboldtstraße 10, 07743, Jena, Germany
| | - Tom Venus
- Institute for Medical Physics and Biophysics, Leipzig University, Härtelstraße 16-18, 04107, Leipzig, Germany
| | - Mandy Geisler
- Institute of Bioanalytical Chemistry, Center for Biotechnology and Biomedicine, Leipzig University, Deutscher Platz 5, 04103, Leipzig, Germany
| | - Veselina Radusheva
- Department of Internal Medicine, Division of Rheumatology, Leipzig University, Liebigstraße 19, 04103, Leipzig, Germany
| | - Stefanie Raps
- Department of Internal Medicine, Division of Rheumatology, Leipzig University, Liebigstraße 19, 04103, Leipzig, Germany
| | - Kathrin Rothe
- Department of Internal Medicine, Division of Rheumatology, Leipzig University, Liebigstraße 19, 04103, Leipzig, Germany
| | - Roger Scholz
- Department of Orthopaedic, Trauma and Plastic Surgery, Leipzig University, Liebigstraße 20, Leipzig, Germany
| | - Sebastian Jung
- Department of Internal Medicine, Division of Rheumatology, Leipzig University, Liebigstraße 19, 04103, Leipzig, Germany
| | - Sylke Wagner
- Department of Internal Medicine, Division of Rheumatology, Leipzig University, Liebigstraße 19, 04103, Leipzig, Germany
| | - Matthias Pierer
- Department of Internal Medicine, Division of Rheumatology, Leipzig University, Liebigstraße 19, 04103, Leipzig, Germany
| | - Olga Seifert
- Department of Internal Medicine, Division of Rheumatology, Leipzig University, Liebigstraße 19, 04103, Leipzig, Germany
| | - Wenhan Chang
- UCSF Department of Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Irina Estrela-Lopis
- Institute for Medical Physics and Biophysics, Leipzig University, Härtelstraße 16-18, 04107, Leipzig, Germany
| | - Nora Raulien
- Department of Internal Medicine, Division of Rheumatology, Leipzig University, Liebigstraße 19, 04103, Leipzig, Germany
| | - Knut Krohn
- DNA Core Unit Leipzig, Liebigstraße 19, 04103, Leipzig, Germany
| | - Norbert Sträter
- Institute of Bioanalytical Chemistry, Center for Biotechnology and Biomedicine, Leipzig University, Deutscher Platz 5, 04103, Leipzig, Germany
| | - Stephanie Hoeppener
- Jena Center for Soft Matter (JCSM), Friedrich-Schiller-University Jena, Humboldtstraße 10, 07743, Jena, Germany
| | - Torsten Schöneberg
- Rudolf Schönheimer Institute of Biochemistry, Faculty of Medicine, Leipzig University, Johannisallee 30, 04103, Leipzig, Germany
| | - Manuela Rossol
- Department of Internal Medicine, Division of Rheumatology, Leipzig University, Liebigstraße 19, 04103, Leipzig, Germany.
| | - Ulf Wagner
- Department of Internal Medicine, Division of Rheumatology, Leipzig University, Liebigstraße 19, 04103, Leipzig, Germany.
| |
Collapse
|
7
|
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.
Collapse
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
| | | |
Collapse
|
8
|
Asada S, Yokoyama K, Miyakoshi C, Fukuma S, Endo Y, Wada M, Nomura T, Onishi Y, Fukagawa M, Fukuhara S, Akizawa T. Relationship between serum calcium or phosphate levels and mortality stratified by parathyroid hormone level: an analysis from the MBD-5D study. Clin Exp Nephrol 2020; 24:630-637. [PMID: 32236781 PMCID: PMC7271007 DOI: 10.1007/s10157-020-01879-8] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 03/14/2020] [Indexed: 10/31/2022]
Abstract
INTRODUCTION There is limited evidence about the association between calcium and phosphate levels and mortality stratified by intact parathyroid hormone (iPTH) level. METHODS We investigated whether differences in iPTH level affect the relationship between calcium and phosphate levels and all-cause mortality in hemodialysis patients with secondary hyperparathyroidism (SHPT). Calcium and phosphate levels were categorized as low (< 8.5 mg/dL, < 4.0 mg/dL), medium (≥ 8.5-< 9.5 mg/dL, ≥ 4.0-< 7.0 mg/dL), and high (≥ 9.5 mg/dL, ≥ 7.0 mg/dL), respectively. iPTH levels were grouped into < 300 or ≥ 300 pg/mL. Adjusted incidence rate ratios (aIRRs) were analyzed by weighted Poisson regression. RESULTS For calcium, patients with higher iPTH (≥ 300 pg/mL) had significantly higher all-cause mortality rates in the high than in the medium category (aIRR 1.99, 95% confidence interval [CI] 1.16-3.42), and tended to have a higher mortality rate in the low category (aIRR 2.04, 95% CI 0.94-4.42). Patients with lower iPTH (< 300 pg/mL) had higher mortality rates in the high than in the medium category (aIRR 1.65, 95% CI 1.39-1.96). For phosphate, the mortality rate was significantly higher in the high than in the medium category in patients with higher and lower iPTH (aIRR 3.23, 95% CI 1.63-6.39 for iPTH ≥ 300 pg/mL; aIRR 1.58, 95% CI 1.06-2.36 for iPTH < 300 pg/mL). CONCLUSION High calcium and phosphate levels were associated with increased risk of mortality irrespective of iPTH level.
Collapse
Affiliation(s)
- Shinji Asada
- Medical Affairs Department, Kyowa Kirin Co., Ltd, Otemachi Financial City Grand Cube, 1-9-2 Otemachi, Chiyoda-ku, Tokyo, 100-0004, Japan.
| | - Keitaro Yokoyama
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, Tokyo, Japan
- Jikei University Harumi Triton Clinic, Jikei University School of Medicine, Tokyo, Japan
| | - Chisato Miyakoshi
- Department of Healthcare Epidemiology, School of Public Health, Faculty of Medicine, Kyoto University, Kyoto, Japan
- Department of Pediatrics, Kobe City Medical Center General Hospital, Kobe, Japan
- Institute for Health Outcomes and Process Evaluation Research (iHope International), Kyoto, Japan
| | - Shingo Fukuma
- Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
- The Keihanshin Consortium for Fostering the Next Generation of Global Leaders in Research (K-CONNEX), Kyoto, Japan
| | - Yuichi Endo
- Medical Affairs Department, Kyowa Kirin Co., Ltd, Otemachi Financial City Grand Cube, 1-9-2 Otemachi, Chiyoda-ku, Tokyo, 100-0004, Japan
| | - Michihito Wada
- Medical Affairs Department, Kyowa Kirin Co., Ltd, Otemachi Financial City Grand Cube, 1-9-2 Otemachi, Chiyoda-ku, Tokyo, 100-0004, Japan
| | - Takanobu Nomura
- Medical Affairs Department, Kyowa Kirin Co., Ltd, Otemachi Financial City Grand Cube, 1-9-2 Otemachi, Chiyoda-ku, Tokyo, 100-0004, Japan
| | - Yoshihiro Onishi
- Institute for Health Outcomes and Process Evaluation Research (iHope International), Kyoto, Japan
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara, Japan
| | - Shunichi Fukuhara
- Department of Healthcare Epidemiology, School of Public Health, Faculty of Medicine, Kyoto University, Kyoto, Japan
| | - Tadao Akizawa
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| |
Collapse
|
9
|
Kakani E, Sloan D, Sawaya BP, El-Husseini A, Malluche HH, Rao M. Long-term outcomes and management considerations after parathyroidectomy in the dialysis patient. Semin Dial 2019; 32:541-552. [PMID: 31313380 DOI: 10.1111/sdi.12833] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Parathyroidectomy (PTX) remains an important intervention for dialysis patients with poorly controlled secondary hyperparathyroidism (SHPT), though there are only retrospective and observational data that show a mortality benefit to this procedure. Potential consequences that we seek to avoid after PTX include persistent or recurrent hyperparathyroidism, and parathyroid insufficiency. There is considerable subjectivity in defining and diagnosing these conditions, given that we poorly understand the optimal PTH targets (particularly post PTX) needed to maintain bone and vascular health. While lowering PTH after PTX decreases bone turnover, long-term changes in bone activity have been poorly explored. High turnover bone disease, usually present at the time a PTX is considered, often swings to a state of low turnover in the setting of sufficiently low PTH levels. It remains unclear if all low bone turnover equate with disease. However, such changes in bone turnover appear to predispose to vascular calcification, with positive calcium balance after PTX being a potential contributor. We know little of how the post-PTX state resets calcium balance, how calcium and VDRA requirements change or what kind of adjustments are needed to avoid calcium loading. The current consensus cautions against excessive reduction of PTH although there is insufficient evidence-based guidance regarding the management of chronic kidney disease - mineral bone disease (CKD-MBD) parameters in the post-PTX state. This article aims to compile existing research, provide an overview of current practice with regard to PTX and post-PTX chronic management. It highlights gaps and controversies and aims to re-orient the focus to clinically relevant contemporary priorities in CKD-MBD management after PTX.
Collapse
Affiliation(s)
- Elijah Kakani
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY, USA
| | - David Sloan
- Division of Endocrine Surgery, University of Kentucky, Lexington, KY, USA
| | - B Peter Sawaya
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY, USA
| | - Amr El-Husseini
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY, USA
| | - Hartmut H Malluche
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY, USA
| | - Madhumathi Rao
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY, USA
| |
Collapse
|
10
|
Schwantes-An TH, Liu S, Stedman M, Decker BS, Wetherill L, Edenberg HJ, Vatta M, Foroud TM, Chertow GM, Moe SM. Fibroblast Growth Factor 23 Genotype and Cardiovascular Disease in Patients Undergoing Hemodialysis. Am J Nephrol 2019; 49:125-132. [PMID: 30669147 PMCID: PMC6473180 DOI: 10.1159/000496060] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 12/04/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Elevated serum concentrations of fibroblast growth factor 23 (FGF23) are associated with cardiovascular mortality in patients with chronic kidney disease and those undergoing dialysis. OBJECTIVES We tested the hypotheses that polymorphisms in FGF23, its co-receptor alpha-klotho (KL), and/or FGF23 receptors (FGFR) are associated with cardiovascular events and/or mortality. METHODS We used 1,494 DNA samples collected at baseline from the Evaluation of Cinacalcet HCl Therapy to Lower Cardiovascular Events Trial, in which patients were randomized to the calcimimetic cinacalcet or placebo for the treatment of secondary hyperparathyroidism. We analyzed European and African Ancestry samples separately and then combined summary statistics to perform a meta-analysis. We evaluated single-nucleotide polymorphisms (SNPs) in FGF23, KL, and FGFR4 as the key exposures of interest in proportional hazards (Cox) regression models using adjudicated endpoints (all-cause and cardiovascular mortality, sudden cardiac death, and heart failure [HF]) as the outcomes of interest. RESULTS rs11063112 in FGF23 was associated with cardiovascular mortality (risk allele = A, hazard ratio [HR] 1.32, meta-p value = 0.004) and HF (HR 1.40, meta-p value = 0.007). No statistically significant associations were observed between FGF23 rs13312789 and SNPs in FGFR4 or KL genes and the outcomes of interest. CONCLUSIONS rs11063112 was associated with HF and cardiovascular mortality in patients receiving dialysis with moderate to severe secondary hyperparathyroidism.
Collapse
Affiliation(s)
- Tae-Hwi Schwantes-An
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Sai Liu
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Margaret Stedman
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Brian S Decker
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Leah Wetherill
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Howard J Edenberg
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Matteo Vatta
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Tatiana M Foroud
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Glenn M Chertow
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Sharon M Moe
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA,
- Roudebush Veterans Administration Medical Center, Indianapolis, Indiana, USA,
| |
Collapse
|
11
|
Incidence, predictors and therapeutic consequences of hypocalcemia in patients treated with cinacalcet in the EVOLVE trial. Kidney Int 2018. [DOI: 10.1016/j.kint.2017.12.014] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
12
|
House AA, Ronco C. Cardiovascular Risk in Hemodialysis Patients: A Mechanistic Approach. Int J Artif Organs 2018; 30:1020-7. [DOI: 10.1177/039139880703001112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A new formula is proposed to express the excess burden of cardiovascular risk faced by hemodialysis patients as a function of various inherent, acquired and potentially modifiable factors. The proposed equation CVRHD = CVRB X f(([CKD+HD]/[HDtech+Dr])+X) includes the terms: CVRHD (cardiovascular risk in hemodialysis patients); CVRB (baseline cardiovascular risk); CKD (risk associated with chronic kidney disease); HD (risks associated with the process of hemodialysis); HDtech (benefits of new hemodialysis technologies); Dr (benefits of drug therapies) and X (unknown or putative factors influencing cardiovascular morbidity). We review the various factors included in this proposed formula, touching upon the epidemiology, pathophysiology and therapeutic implications, including possible strategies to modify risk. As is apparent from the formula, CKD and HD in particular act as risk multipliers in augmenting or amplifying the baseline cardiovascular risk, while new hemodialysis technologies may provide an opportunity for “cardioprotective dialysis.” Drug treatment may serve to mitigate some of the risk unique to this population.
Collapse
Affiliation(s)
- A. A. House
- University of Western Ontario Division of Nephrology, University Hospital, London Health Sciences Centre, London, Ontario - Canada
| | - C. Ronco
- Department of Nephrology Dialysis and Transplantation, St. Bortolo Hospital, Vicenza - Italy
| |
Collapse
|
13
|
Abstract
The discovery of fibroblast growth factor 23 (FGF23) has provided a more complete understanding of the regulation of phosphate and mineral homeostasis in health and in chronic kidney disease. It has also offered new insights into stratification of risk of cardiovascular events and death among patients with chronic kidney disease and the general population. In this review, we provide an overview of FGF23 biology and physiology, summarize clinical outcomes that have been associated with FGF23, discuss potential mechanisms for these observations and their public health implications, and explore clinical and population health interventions that aim to reduce FGF23 levels and improve public health.
Collapse
Affiliation(s)
- Lindsay R Pool
- Center for Translational Health and Metabolism, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611;
| | - Myles Wolf
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina 27703;
| |
Collapse
|
14
|
Moe SM, Wetherill L, Decker BS, Lai D, Abdalla S, Long J, Vatta M, Foroud TM, Chertow GM. Calcium-Sensing Receptor Genotype and Response to Cinacalcet in Patients Undergoing Hemodialysis. Clin J Am Soc Nephrol 2017; 12:1128-1138. [PMID: 28630081 PMCID: PMC5498355 DOI: 10.2215/cjn.11141016] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 03/23/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES We tested the hypothesis that single nucleotide polymorphisms (SNPs) in the calcium-sensing receptor (CASR) alter the response to the calcimimetic cinacalcet. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We analyzed DNA samples in the Evaluation of Cinacalcet HCl Therapy to Lower Cardiovascular Events (EVOLVE) trial, a randomized trial comparing cinacalcet to placebo on a background of usual care. Of the 3883 patients randomized, 1919 (49%) consented to DNA collection, and samples from 1852 participants were genotyped for 18 CASR polymorphisms. The European ancestry (EA; n=1067) and African ancestry (AfAn; n=405) groups were assessed separately. SNPs in CASR were tested for their association with biochemical measures of mineral metabolism at baseline, percent change from baseline to 20 weeks, and risk of clinical fracture as dependent variables. RESULTS There were modest associations of CASR SNPs with increased baseline serum parathyroid hormone and bone alkaline phosphatase primarily with the minor allele in the EA group (all P≤0.03), but not in the AfAn sample. In contrast, there was a modest association of decreased baseline serum calcium and FGF23 with CASR SNPs (P=0.04) primarily with the minor allele in the AfAn but not in the EA sample. The minor allele of two SNPs was associated with decreased percent reduction in parathyroid hormone from baseline to 20 weeks in the EA population (P<0.04) and this was not altered with cinacalcet. In both EA and AfAn, the same SNP (rs9740) was associated with decreased calcium with cinacalcet treatment (EA and AfAn P≤0.03). Three SNPs in high linkage disequilibrium were associated with a higher risk of clinical fracture that was attenuated by cinacalcet treatment in the EA sample (P<0.04). CONCLUSIONS These modest associations, if validated, may provide explanations for differences in CKD-mineral bone disorder observed in EA and AfAn populations, and for differential biochemical responses to calcimimetics.
Collapse
Affiliation(s)
- Sharon M. Moe
- Division of Nephrology, Department of Medicine and
- Department of Medicine, Roudebush Veterans Administration Medical Center, Indianapolis, Indiana; and
| | - Leah Wetherill
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Dongbing Lai
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Safa Abdalla
- Division of Nephrology, Department of Medicine, Stanford School of Medicine, Stanford, California
| | - Jin Long
- Division of Nephrology, Department of Medicine, Stanford School of Medicine, Stanford, California
| | - Matteo Vatta
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Tatiana M. Foroud
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Glenn M. Chertow
- Division of Nephrology, Department of Medicine, Stanford School of Medicine, Stanford, California
| |
Collapse
|
15
|
Krishnasamy R, Pedagogos E. Should nephrologists consider vascular calcification screening? Nephrology (Carlton) 2017; 22 Suppl 2:31-33. [PMID: 28429546 DOI: 10.1111/nep.13019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Vascular calcification (VC) has been widely discussed over the last few decades and is associated with significant morbidity and mortality among patients with chronic kidney disease. Importantly, these patients have premature and rapidly progressive calcification when compared with the general population. VC is an active and complex process that is closely regulated by a growing list of inducers and inhibitors. VC can be detected using several non-invasive modalities including plain radiography, echocardiogram and computed tomography scans. However, the usefulness of these imaging measurements to capture treatment effects may be limited. Routine screening and monitoring for progression of VC remains highly debatable.
Collapse
Affiliation(s)
- Rathika Krishnasamy
- Department of Nephrology, Nambour General Hospital, Nambour, Queensland, Australia.,The University of Queensland, Brisbane, Queensland, Australia
| | - Eugenie Pedagogos
- Epworth Health Care, Melbourne, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
16
|
Portillo MR, Rodríguez-Ortiz ME. Secondary Hyperparthyroidism: Pathogenesis, Diagnosis, Preventive and Therapeutic Strategies. Rev Endocr Metab Disord 2017; 18:79-95. [PMID: 28378123 DOI: 10.1007/s11154-017-9421-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Uremic secondary hyperparathyroidism is a multifactorial and complex disease often present in advanced stages of chronic kidney disease. The accumulation of phosphate, the increased FGF23 levels, the reduction in active vitamin D production, and the tendency to hypocalcemia are persistent stimuli for the development and progression of parathyroid hyperplasia with increased secretion of PTH. Parathyroid proliferation may become nodular mainly in cases of advanced hyperparathyroidism. The alterations in the regulation of mineral metabolism, the development of bone disease and extraosseous calcifications are essential components of chronic kidney disease-mineral and bone disorder and have been associated with negative outcomes. The management of hyperparathyroidism includes the correction of vitamin D deficiency and control of serum phosphorus and PTH without inducing hypercalcemia. An update of the leading therapeutic tools available for the prevention and clinical management of secondary hyperparathyroidism, its diagnosis, and the main mechanisms and factors involved in the pathogenesis of the disease will be described in this review.
Collapse
Affiliation(s)
- Mariano Rodríguez Portillo
- Nephrology Service, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Reina Sofía University Hospital/University of Córdoba, Avda. Menéndez Pidal, S/N, 14004, Córdoba, Spain.
- REDinREN, Madrid, Spain.
| | | |
Collapse
|
17
|
Pasch A, Block GA, Bachtler M, Smith ER, Jahnen-Dechent W, Arampatzis S, Chertow GM, Parfrey P, Ma X, Floege J. Blood Calcification Propensity, Cardiovascular Events, and Survival in Patients Receiving Hemodialysis in the EVOLVE Trial. Clin J Am Soc Nephrol 2017; 12:315-322. [PMID: 27940458 PMCID: PMC5293330 DOI: 10.2215/cjn.04720416] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 10/11/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVES Patients receiving hemodialysis are at risk of cardiovascular events. A novel blood test (T50 test) determines the individual calcification propensity of blood. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS T50 was determined in 2785 baseline serum samples of patients receiving hemodialysis enrolled in the Evaluation of Cinacalcet Therapy to Lower Cardiovascular Events (EVOLVE) trial and the T50 results were related to patient outcomes. RESULTS Serum albumin, bicarbonate, HDL cholesterol, and creatinine were the main factors positively/directly and phosphate was the main factor negatively/inversely associated with T50. The primary composite end point (all-cause mortality, myocardial infarction [MI], hospitalization for unstable angina, heart failure, or peripheral vascular event [PVE]) was reached in 1350 patients after a median follow-up time of 619 days. After adjustments for confounding, a lower T50 was independently associated with a higher risk of the primary composite end point as a continuous measure (hazard ratio [HR] per 1 SD lower T50, 1.15; 95% confidence interval [95% CI], 1.08 to 1.22; P<0.001). Furthermore, lower T50 was associated with a higher risk in all-cause mortality (HR per 1 SD lower T50, 1.10; 95% CI, 1.02 to 1.17; P=0.001), MI (HR per 1 SD lower T50, 1.38; 95% CI, 1.19 to 1.60; P<0.001), and PVE (HR per 1 SD lower T50, 1.22; 95% CI, 1.05 to 1.42; P=0.01). T50 improved risk prediction (integrated discrimination improvement and net reclassification improvement, P<0.001 and P=0.001) of the primary composite end point. CONCLUSIONS Blood calcification propensity was independently associated with the primary composite end point, all-cause mortality, MI, and PVE in the EVOLVE study and improved risk prediction. Prospective trials should clarify whether T50-guided therapies improve outcomes.
Collapse
Affiliation(s)
| | | | | | - Edward R. Smith
- The Royal Melbourne Hospital, Victoria, Melbourne, Australia
| | | | | | | | - Patrick Parfrey
- Health Sciences Center, St. John’s, Newfoundland, Canada; and
| | | | - Juergen Floege
- Rheinisch-Westfaelische Technische Hochschule University of Aachen, Aachen, Germany
| |
Collapse
|
18
|
NasrAllah MM, Nassef A, Elshaboni TH, Morise F, Osman NA, Sharaf El Din UA. Comparing different calcification scores to detect outcomes in chronic kidney disease patients with vascular calcification. Int J Cardiol 2016; 220:884-9. [PMID: 27400189 DOI: 10.1016/j.ijcard.2016.06.064] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 06/19/2016] [Indexed: 02/09/2023]
Abstract
BACKGROUND There is no consensus on the most appropriate technique to diagnose vascular calcification in chronic kidney disease. This is primarily because of the absence of direct comparisons of predictive values of the various calcification scores, especially outside the coronary vascular beds, to detect clinical outcomes. METHODS We included 93 haemodialysis patients and performed 6 vascular calcification scores: two scores utilised simple X-rays of abdominal aorta and peripheral vessels. CT scans of the thoracic, upper abdominal and lower abdominal aorta were performed to calculate the aortic calcification index and CT of the pelvis for calcification of iliac vessels. Patients were followed for 63months (mean 46.8months) for first major cardiovascular events and mortality. RESULTS Nineteen cardiovascular events and 28 deaths occurred. Calcification was detected more sensitively in central and peripheral beds using CT scans compared to X-rays (p<0.001). CT scans detected calcification more frequently in distal than proximal vascular beds (p<0.001). Calcification of the pelvic vessels and lower abdominal aorta were most predictive of events including pre-existing cardiovascular disease O.R. 6.5 (95% C.I. 2-22; p=0.001) and O.R. 3 (95% C.I. 1.1-9; p=0.035); new major cardiovascular events H.R. 4.2 (95% C.I. 1.5-11; p=0.006) and H.R. 2 (95% C.I. 0.8-5.3; p=0.1) as well as mortality H.R. 2.8 (95% C.I. 1.3-6; p=0.01) and H.R. 2.2 (95% C.I. 1.04-5; p=0.04) respectively. CONCLUSIONS CT based techniques are more sensitive than plain X-rays at detecting peripheral and aortic vascular calcifications. Distal CT scans of the aorta and pelvic vessels have the highest predictive value for cardiovascular events and mortality.
Collapse
Affiliation(s)
- Mohamed M NasrAllah
- Kasr AlAiny School of Medicine, Cairo University, Nephrology, Saray Street, Manial, Cairo, Egypt.
| | - Amr Nassef
- Kasr AlAiny School of Medicine, Cairo University, Radiology, Cairo, Egypt
| | - Tarik H Elshaboni
- Kasr AlAiny School of Medicine, Cairo University, Nephrology, Saray Street, Manial, Cairo, Egypt
| | - Fadia Morise
- Kasr AlAiny School of Medicine, Cairo University, Nephrology, Saray Street, Manial, Cairo, Egypt
| | - Noha A Osman
- Kasr AlAiny School of Medicine, Cairo University, Nephrology, Saray Street, Manial, Cairo, Egypt
| | - Usama A Sharaf El Din
- Kasr AlAiny School of Medicine, Cairo University, Nephrology, Saray Street, Manial, Cairo, Egypt
| |
Collapse
|
19
|
The win ratio approach to analyzing composite outcomes: An application to the EVOLVE trial. Contemp Clin Trials 2016; 48:119-24. [DOI: 10.1016/j.cct.2016.04.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 03/17/2016] [Accepted: 04/05/2016] [Indexed: 10/22/2022]
|
20
|
Briggs AH, Parfrey PS, Khan N, Tseng S, Dehmel B, Kubo Y, Chertow GM, Belozeroff V. Analyzing Health-Related Quality of Life in the EVOLVE Trial: The Joint Impact of Treatment and Clinical Events. Med Decis Making 2016; 36:965-72. [PMID: 26987347 DOI: 10.1177/0272989x16638312] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 12/01/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Evaluation of Cinacalcet HCl Therapy to Lower Cardiovascular Events (EVOLVE) clinical trial evaluated the effects of cinacalcet on clinical events in patients with secondary hyperparathyroidism (sHPT) who were on hemodialysis. Health-related quality of life (HRQoL) was assessed by a generic, preference-based health outcome measure (EQ-5D) at scheduled visits and after a study event. Here, we report the HRQoL analysis from EVOLVE. METHODS We assessed changes in HRQoL from baseline to scheduled visits, and estimated the acute (3 mo) and chronic (beyond 3 mo) effects of sHPT-related events on HRQoL using generalized estimating equation analysis controlling for baseline HRQoL and randomized assignment. RESULTS Data on HRQoL were available for 3547 of 3883 subjects, with 1650 events in the placebo and 1502 in the cinacalcet arm. At the study end, no difference in change from baseline HRQoL was observed in the direct comparison of EQ-5D by treatment arms. The regression analysis showed significant effects of events on HRQoL and a modest positive effect of cinacalcet. Estimated quality-adjusted life-year gains were of similar magnitude based on the observed data or the predictions from the model, with only a small gain in precision from the predicted analysis. CONCLUSIONS By contrast with a conventional comparison, a regression analysis demonstrated large decrements in HRQoL after events and a modest improvement in HRQoL with cinacalcet. As randomized controlled trials are rarely powered to detect differences in HRQoL, a prespecified regression analysis may be acceptable to improve precision of the effects and understand their origin.
Collapse
Affiliation(s)
- Andrew H Briggs
- Health Economics & Health Technology Assessment, University of Glasgow, UK (AHB)
| | | | | | | | | | - Yumi Kubo
- Amgen Inc., Thousand Oaks, CA (ST, BD, YK, VB)
| | | | | |
Collapse
|
21
|
Pun PH, Abdalla S, Block GA, Chertow GM, Correa-Rotter R, Dehmel B, Drüeke TB, Floege J, Goodman WG, Herzog CA, London GM, Mahaffey KW, Moe SM, Parfrey PS, Wheeler DC, Middleton JP. Cinacalcet, dialysate calcium concentration, and cardiovascular events in the EVOLVE trial. Hemodial Int 2015; 20:421-31. [PMID: 26564024 DOI: 10.1111/hdi.12382] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Among patients receiving hemodialysis, abnormalities in calcium regulation have been linked to an increased risk of cardiovascular events. Cinacalcet lowers serum calcium concentrations through its effect on parathyroid hormone secretion and has been hypothesized to reduce the risk of cardiovascular events. In observational cohort studies, prescriptions of low dialysate calcium concentration and larger observed serum-dialysate calcium gradients have been associated with higher risks of in-dialysis facility or peri-dialytic sudden cardiac arrest. We performed this study to examine the risks associated with dialysate calcium and serum-dialysate gradients among participants in the Evaluation of Cinacalcet Hydrochloride Therapy to Lower Cardiovascular Events (EVOLVE) trial. In EVOLVE, 3883 hemodialysis patients were randomized 1:1 to cinacalcet or placebo. Dialysate calcium was administered at the discretion of treating physicians. We examined whether baseline dialysate calcium concentration or the serum-dialysate calcium gradient modified the effect of cinacalcet on the following adjudicated endpoints: (1) primary composite endpoint (death or first non-fatal myocardial infarction, hospitalization for unstable angina, heart failure, or peripheral vascular event); (2) cardiovascular death; and (3) sudden death. In EVOLVE, use of higher dialysate calcium concentrations was more prevalent in Europe and Latin America compared with North America. There was a significant fall in serum calcium concentration in the cinacalcet group; dialysate calcium concentrations were changed infrequently in both groups. There was no association between baseline dialysate calcium concentration or serum-dialysate calcium gradient and the endpoints examined. Neither the baseline dialysate calcium nor the serum-dialysate calcium gradient significantly modified the effects of cinacalcet on the outcomes examined. The effects of cinacalcet on cardiovascular death and major cardiovascular events are not altered by the dialysate calcium prescription and serum-dialysate calcium gradient.
Collapse
Affiliation(s)
- Patrick H Pun
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Safa Abdalla
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | | | - Glenn M Chertow
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ricardo Correa-Rotter
- Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, District Federal, Mexico
| | | | - Tilman B Drüeke
- Inserm Unit 1088, UFR Médecine/Pharmacie, Université de Picardie, Amiens, France
| | - Jürgen Floege
- Department of Nephrology, Universitätsklinikum der RWTH Aachen, Aachen, Germany
| | | | | | - Gerard M London
- Hôpital Manhès, Paris, France.,Indiana University School of Medicine and Roudebush Veterans Administration Medical Center, Indianapolis, Indiana, USA
| | - Kenneth W Mahaffey
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Sharon M Moe
- Hôpital Manhès, Paris, France.,Indiana University School of Medicine and Roudebush Veterans Administration Medical Center, Indianapolis, Indiana, USA
| | | | | | - John P Middleton
- Department of Medicine, Duke University, Durham, North Carolina, USA
| |
Collapse
|
22
|
Moe SM, Chertow GM, Parfrey PS, Kubo Y, Block GA, Correa-Rotter R, Drüeke TB, Herzog CA, London GM, Mahaffey KW, Wheeler DC, Stolina M, Dehmel B, Goodman WG, Floege J. Cinacalcet, Fibroblast Growth Factor-23, and Cardiovascular Disease in Hemodialysis: The Evaluation of Cinacalcet HCl Therapy to Lower Cardiovascular Events (EVOLVE) Trial. Circulation 2015; 132:27-39. [PMID: 26059012 DOI: 10.1161/circulationaha.114.013876] [Citation(s) in RCA: 210] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 04/22/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with kidney disease have disordered bone and mineral metabolism, including elevated serum concentrations of fibroblast growth factor-23 (FGF23). These elevated concentrations are associated with cardiovascular and all-cause mortality. The objective was to determine the effects of the calcimimetic cinacalcet (versus placebo) on reducing serum FGF23 and whether changes in FGF23 are associated with death and cardiovascular events. METHODS AND RESULTS This was a secondary analysis of a randomized clinical trial comparing cinacalcet to placebo in addition to conventional therapy (phosphate binders/vitamin D) in patients receiving hemodialysis with secondary hyperparathyroidism (intact parathyroid hormone ≥300 pg/mL). The primary study end point was time to death or a first nonfatal cardiovascular event (myocardial infarction, hospitalization for angina, heart failure, or a peripheral vascular event). This analysis included 2985 patients (77% of randomized) with serum samples at baseline and 2602 patients (67%) with samples at both baseline and week 20. The results demonstrated that a significantly larger proportion of patients randomized to cinacalcet had ≥30% (68% versus 28%) reductions in FGF23. Among patients randomized to cinacalcet, a ≥30% reduction in FGF23 between baseline and week 20 was associated with a nominally significant reduction in the primary composite end point (relative hazard, 0.82; 95% confidence interval, 0.69-0.98), cardiovascular mortality (relative hazard, 0.66; 95% confidence interval, 0.50-0.87), sudden cardiac death (relative hazard, 0.57; 95% confidence interval, 0.37-0.86), and heart failure (relative hazard, 0.69; 95% confidence interval, 0.48-0.99). CONCLUSIONS Treatment with cinacalcet significantly lowers serum FGF23. Treatment-induced reductions in serum FGF23 are associated with lower rates of cardiovascular death and major cardiovascular events. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00345839.
Collapse
Affiliation(s)
- Sharon M Moe
- From Indiana University School of Medicine and Roudebush Veterans Administration Medical Center, Indianapolis (S.M.M.); Stanford University School of Medicine, Palo Alto, CA (G.M.C., K.W.M.); Health Sciences Center, St. John's, NL, Canada (P.S.P.); Amgen Inc, Thousand Oaks, CA (Y.K., M.S., B.D., W.G.G.); Denver Nephrology, CO (G.A.B.); Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico (R.C.-R.); Inserm Unit 1088, UFR Médecine/Pharmacie, Université de Picardie, Amiens, France (T.B.D.); University of Minnesota, Minneapolis (C.A.H.); Hôpital Manhès, Paris, France (G.M.L.); University College London, London, UK (D.C.W.); and Universitätsklinikum der RWTH Aachen, Germany (J.F.).
| | - Glenn M Chertow
- From Indiana University School of Medicine and Roudebush Veterans Administration Medical Center, Indianapolis (S.M.M.); Stanford University School of Medicine, Palo Alto, CA (G.M.C., K.W.M.); Health Sciences Center, St. John's, NL, Canada (P.S.P.); Amgen Inc, Thousand Oaks, CA (Y.K., M.S., B.D., W.G.G.); Denver Nephrology, CO (G.A.B.); Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico (R.C.-R.); Inserm Unit 1088, UFR Médecine/Pharmacie, Université de Picardie, Amiens, France (T.B.D.); University of Minnesota, Minneapolis (C.A.H.); Hôpital Manhès, Paris, France (G.M.L.); University College London, London, UK (D.C.W.); and Universitätsklinikum der RWTH Aachen, Germany (J.F.)
| | - Patrick S Parfrey
- From Indiana University School of Medicine and Roudebush Veterans Administration Medical Center, Indianapolis (S.M.M.); Stanford University School of Medicine, Palo Alto, CA (G.M.C., K.W.M.); Health Sciences Center, St. John's, NL, Canada (P.S.P.); Amgen Inc, Thousand Oaks, CA (Y.K., M.S., B.D., W.G.G.); Denver Nephrology, CO (G.A.B.); Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico (R.C.-R.); Inserm Unit 1088, UFR Médecine/Pharmacie, Université de Picardie, Amiens, France (T.B.D.); University of Minnesota, Minneapolis (C.A.H.); Hôpital Manhès, Paris, France (G.M.L.); University College London, London, UK (D.C.W.); and Universitätsklinikum der RWTH Aachen, Germany (J.F.)
| | - Yumi Kubo
- From Indiana University School of Medicine and Roudebush Veterans Administration Medical Center, Indianapolis (S.M.M.); Stanford University School of Medicine, Palo Alto, CA (G.M.C., K.W.M.); Health Sciences Center, St. John's, NL, Canada (P.S.P.); Amgen Inc, Thousand Oaks, CA (Y.K., M.S., B.D., W.G.G.); Denver Nephrology, CO (G.A.B.); Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico (R.C.-R.); Inserm Unit 1088, UFR Médecine/Pharmacie, Université de Picardie, Amiens, France (T.B.D.); University of Minnesota, Minneapolis (C.A.H.); Hôpital Manhès, Paris, France (G.M.L.); University College London, London, UK (D.C.W.); and Universitätsklinikum der RWTH Aachen, Germany (J.F.)
| | - Geoffrey A Block
- From Indiana University School of Medicine and Roudebush Veterans Administration Medical Center, Indianapolis (S.M.M.); Stanford University School of Medicine, Palo Alto, CA (G.M.C., K.W.M.); Health Sciences Center, St. John's, NL, Canada (P.S.P.); Amgen Inc, Thousand Oaks, CA (Y.K., M.S., B.D., W.G.G.); Denver Nephrology, CO (G.A.B.); Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico (R.C.-R.); Inserm Unit 1088, UFR Médecine/Pharmacie, Université de Picardie, Amiens, France (T.B.D.); University of Minnesota, Minneapolis (C.A.H.); Hôpital Manhès, Paris, France (G.M.L.); University College London, London, UK (D.C.W.); and Universitätsklinikum der RWTH Aachen, Germany (J.F.)
| | - Ricardo Correa-Rotter
- From Indiana University School of Medicine and Roudebush Veterans Administration Medical Center, Indianapolis (S.M.M.); Stanford University School of Medicine, Palo Alto, CA (G.M.C., K.W.M.); Health Sciences Center, St. John's, NL, Canada (P.S.P.); Amgen Inc, Thousand Oaks, CA (Y.K., M.S., B.D., W.G.G.); Denver Nephrology, CO (G.A.B.); Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico (R.C.-R.); Inserm Unit 1088, UFR Médecine/Pharmacie, Université de Picardie, Amiens, France (T.B.D.); University of Minnesota, Minneapolis (C.A.H.); Hôpital Manhès, Paris, France (G.M.L.); University College London, London, UK (D.C.W.); and Universitätsklinikum der RWTH Aachen, Germany (J.F.)
| | - Tilman B Drüeke
- From Indiana University School of Medicine and Roudebush Veterans Administration Medical Center, Indianapolis (S.M.M.); Stanford University School of Medicine, Palo Alto, CA (G.M.C., K.W.M.); Health Sciences Center, St. John's, NL, Canada (P.S.P.); Amgen Inc, Thousand Oaks, CA (Y.K., M.S., B.D., W.G.G.); Denver Nephrology, CO (G.A.B.); Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico (R.C.-R.); Inserm Unit 1088, UFR Médecine/Pharmacie, Université de Picardie, Amiens, France (T.B.D.); University of Minnesota, Minneapolis (C.A.H.); Hôpital Manhès, Paris, France (G.M.L.); University College London, London, UK (D.C.W.); and Universitätsklinikum der RWTH Aachen, Germany (J.F.)
| | - Charles A Herzog
- From Indiana University School of Medicine and Roudebush Veterans Administration Medical Center, Indianapolis (S.M.M.); Stanford University School of Medicine, Palo Alto, CA (G.M.C., K.W.M.); Health Sciences Center, St. John's, NL, Canada (P.S.P.); Amgen Inc, Thousand Oaks, CA (Y.K., M.S., B.D., W.G.G.); Denver Nephrology, CO (G.A.B.); Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico (R.C.-R.); Inserm Unit 1088, UFR Médecine/Pharmacie, Université de Picardie, Amiens, France (T.B.D.); University of Minnesota, Minneapolis (C.A.H.); Hôpital Manhès, Paris, France (G.M.L.); University College London, London, UK (D.C.W.); and Universitätsklinikum der RWTH Aachen, Germany (J.F.)
| | - Gerard M London
- From Indiana University School of Medicine and Roudebush Veterans Administration Medical Center, Indianapolis (S.M.M.); Stanford University School of Medicine, Palo Alto, CA (G.M.C., K.W.M.); Health Sciences Center, St. John's, NL, Canada (P.S.P.); Amgen Inc, Thousand Oaks, CA (Y.K., M.S., B.D., W.G.G.); Denver Nephrology, CO (G.A.B.); Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico (R.C.-R.); Inserm Unit 1088, UFR Médecine/Pharmacie, Université de Picardie, Amiens, France (T.B.D.); University of Minnesota, Minneapolis (C.A.H.); Hôpital Manhès, Paris, France (G.M.L.); University College London, London, UK (D.C.W.); and Universitätsklinikum der RWTH Aachen, Germany (J.F.)
| | - Kenneth W Mahaffey
- From Indiana University School of Medicine and Roudebush Veterans Administration Medical Center, Indianapolis (S.M.M.); Stanford University School of Medicine, Palo Alto, CA (G.M.C., K.W.M.); Health Sciences Center, St. John's, NL, Canada (P.S.P.); Amgen Inc, Thousand Oaks, CA (Y.K., M.S., B.D., W.G.G.); Denver Nephrology, CO (G.A.B.); Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico (R.C.-R.); Inserm Unit 1088, UFR Médecine/Pharmacie, Université de Picardie, Amiens, France (T.B.D.); University of Minnesota, Minneapolis (C.A.H.); Hôpital Manhès, Paris, France (G.M.L.); University College London, London, UK (D.C.W.); and Universitätsklinikum der RWTH Aachen, Germany (J.F.)
| | - David C Wheeler
- From Indiana University School of Medicine and Roudebush Veterans Administration Medical Center, Indianapolis (S.M.M.); Stanford University School of Medicine, Palo Alto, CA (G.M.C., K.W.M.); Health Sciences Center, St. John's, NL, Canada (P.S.P.); Amgen Inc, Thousand Oaks, CA (Y.K., M.S., B.D., W.G.G.); Denver Nephrology, CO (G.A.B.); Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico (R.C.-R.); Inserm Unit 1088, UFR Médecine/Pharmacie, Université de Picardie, Amiens, France (T.B.D.); University of Minnesota, Minneapolis (C.A.H.); Hôpital Manhès, Paris, France (G.M.L.); University College London, London, UK (D.C.W.); and Universitätsklinikum der RWTH Aachen, Germany (J.F.)
| | - Maria Stolina
- From Indiana University School of Medicine and Roudebush Veterans Administration Medical Center, Indianapolis (S.M.M.); Stanford University School of Medicine, Palo Alto, CA (G.M.C., K.W.M.); Health Sciences Center, St. John's, NL, Canada (P.S.P.); Amgen Inc, Thousand Oaks, CA (Y.K., M.S., B.D., W.G.G.); Denver Nephrology, CO (G.A.B.); Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico (R.C.-R.); Inserm Unit 1088, UFR Médecine/Pharmacie, Université de Picardie, Amiens, France (T.B.D.); University of Minnesota, Minneapolis (C.A.H.); Hôpital Manhès, Paris, France (G.M.L.); University College London, London, UK (D.C.W.); and Universitätsklinikum der RWTH Aachen, Germany (J.F.)
| | - Bastian Dehmel
- From Indiana University School of Medicine and Roudebush Veterans Administration Medical Center, Indianapolis (S.M.M.); Stanford University School of Medicine, Palo Alto, CA (G.M.C., K.W.M.); Health Sciences Center, St. John's, NL, Canada (P.S.P.); Amgen Inc, Thousand Oaks, CA (Y.K., M.S., B.D., W.G.G.); Denver Nephrology, CO (G.A.B.); Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico (R.C.-R.); Inserm Unit 1088, UFR Médecine/Pharmacie, Université de Picardie, Amiens, France (T.B.D.); University of Minnesota, Minneapolis (C.A.H.); Hôpital Manhès, Paris, France (G.M.L.); University College London, London, UK (D.C.W.); and Universitätsklinikum der RWTH Aachen, Germany (J.F.)
| | - William G Goodman
- From Indiana University School of Medicine and Roudebush Veterans Administration Medical Center, Indianapolis (S.M.M.); Stanford University School of Medicine, Palo Alto, CA (G.M.C., K.W.M.); Health Sciences Center, St. John's, NL, Canada (P.S.P.); Amgen Inc, Thousand Oaks, CA (Y.K., M.S., B.D., W.G.G.); Denver Nephrology, CO (G.A.B.); Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico (R.C.-R.); Inserm Unit 1088, UFR Médecine/Pharmacie, Université de Picardie, Amiens, France (T.B.D.); University of Minnesota, Minneapolis (C.A.H.); Hôpital Manhès, Paris, France (G.M.L.); University College London, London, UK (D.C.W.); and Universitätsklinikum der RWTH Aachen, Germany (J.F.)
| | - Jürgen Floege
- From Indiana University School of Medicine and Roudebush Veterans Administration Medical Center, Indianapolis (S.M.M.); Stanford University School of Medicine, Palo Alto, CA (G.M.C., K.W.M.); Health Sciences Center, St. John's, NL, Canada (P.S.P.); Amgen Inc, Thousand Oaks, CA (Y.K., M.S., B.D., W.G.G.); Denver Nephrology, CO (G.A.B.); Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico (R.C.-R.); Inserm Unit 1088, UFR Médecine/Pharmacie, Université de Picardie, Amiens, France (T.B.D.); University of Minnesota, Minneapolis (C.A.H.); Hôpital Manhès, Paris, France (G.M.L.); University College London, London, UK (D.C.W.); and Universitätsklinikum der RWTH Aachen, Germany (J.F.)
| | | |
Collapse
|
23
|
The effects of cinacalcet on blood pressure, mortality and cardiovascular endpoints in the EVOLVE trial. J Hum Hypertens 2015; 30:204-9. [DOI: 10.1038/jhh.2015.56] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 04/09/2015] [Accepted: 04/29/2015] [Indexed: 11/08/2022]
|
24
|
Moe SM, Abdalla S, Chertow GM, Parfrey PS, Block GA, Correa-Rotter R, Floege J, Herzog CA, London GM, Mahaffey KW, Wheeler DC, Dehmel B, Goodman WG, Drüeke TB. Effects of Cinacalcet on Fracture Events in Patients Receiving Hemodialysis: The EVOLVE Trial. J Am Soc Nephrol 2015; 26:1466-75. [PMID: 25505257 PMCID: PMC4446874 DOI: 10.1681/asn.2014040414] [Citation(s) in RCA: 130] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 09/07/2014] [Indexed: 11/03/2022] Open
Abstract
Fractures are frequent in patients receiving hemodialysis. We tested the hypothesis that cinacalcet would reduce the rate of clinical fractures in patients receiving hemodialysis using data from the Evaluation of Cinacalcet HCl Therapy to Lower Cardiovascular Events trial, a placebo-controlled trial that randomized 3883 hemodialysis patients with secondary hyperparathyroidism to receive cinacalcet or placebo for ≤64 months. This study was a prespecified secondary analysis of the trial whose primary end point was all-cause mortality and non-fatal cardiovascular events, and one of the secondary end points was first clinical fracture event. Clinical fractures were observed in 255 of 1935 (13.2%) patients randomized to placebo and 238 of 1948 (12.2%) patients randomized to cinacalcet. In an unadjusted intention-to-treat analysis, the relative hazard for fracture (cinacalcet versus placebo) was 0.89 (95% confidence interval [95% CI], 0.75 to 1.07). After adjustment for baseline characteristics and multiple fractures, the relative hazard was 0.83 (95% CI, 0.72 to 0.98). Using a prespecified lag-censoring analysis (a measure of actual drug exposure), the relative hazard for fracture was 0.72 (95% CI, 0.58 to 0.90). When participants were censored at the time of cointerventions (parathyroidectomy, transplant, or provision of commercial cinacalcet), the relative hazard was 0.71 (95% CI, 0.58 to 0.87). Fracture rates were higher in older compared with younger patients and the effect of cinacalcet appeared more pronounced in older patients. In conclusion, using an unadjusted intention-to-treat analysis, cinacalcet did not reduce the rate of clinical fracture. However, when accounting for differences in baseline characteristics, multiple fractures, and/or events prompting discontinuation of study drug, cinacalcet reduced the rate of clinical fracture by 16%-29%.
Collapse
Affiliation(s)
- Sharon M Moe
- Indiana University School of Medicine and Roudebush Veterans Administration Medical Center, Indianapolis, Indiana;
| | - Safa Abdalla
- Stanford University School of Medicine, Palo Alto, California
| | - Glenn M Chertow
- Stanford University School of Medicine, Palo Alto, California
| | | | | | - Ricardo Correa-Rotter
- Salvador Zubirán National Institute of Medical Sciences and Nutrition, Mexico City, Mexico
| | | | | | | | | | | | | | | | - Tilman B Drüeke
- French Institute of Health and Medical Research (INSERM) Unit 1088, Faculty of Medicine/Pharmacy, University of Picardie, Amiens, France
| |
Collapse
|
25
|
Magnabosco FF, Tavares MR, Montenegro FLDM. [Surgical treatment of secondary hyperparathyroidism: a systematic review of the literature]. ACTA ACUST UNITED AC 2015; 58:562-71. [PMID: 25166048 DOI: 10.1590/0004-2730000003372] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 05/12/2014] [Indexed: 11/22/2022]
Abstract
Secondary hyperparathyroidism (HPT) has a high prevalence in renal patients. Secondary HPT results from disturbances in mineral homeostasis, particularly calcium, which stimulates the parathyroid glands, increasing the secretion of parathyroid hormone (PTH). Prolonged stimulation can lead to autonomy in parathyroid function. Initial treatment is clinical, but parathyroidectomy (PTx) may be required. PTx can be subtotal or total followed or not followed by parathyroid tissue autograft. We compared the indications and results of these strategies as shown in the literature through a systematic literature review on surgical treatment of secondary HPT presented in MedLine and LILACS from January 2008 to March 2014. The search terms were: hyperparathyroidism; secondary hyperparathyroidism; parathyroidectomy and parathyroid glands, restricted to research only in humans, articles available in electronic media, published in Portuguese, Spanish, English or French. We selected 49 articles. Subtotal and total PTx followed by parathyroid tissue autograft were the most used techniques, without consensus on the most effective surgical procedure, although there was a preference for the latter. The choice depends on surgeon's experience. There was consensus on the need to identify all parathyroid glands and cryopreservation of parathyroid tissue whenever possible to graft if hypoparathyroidism arise. Imaging studies may be useful, especially in recurrences. Alternative treatments of secondary HPT, both interventional and conservative, require further study.
Collapse
Affiliation(s)
| | - Marcos Roberto Tavares
- Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
| | | |
Collapse
|
26
|
Zoccali C, Bolignano D, D'Arrigo G, Dekker FW, Fliser D, Heine GH, Jager KJ, Kanbay M, Mallamaci F, Massy Z, Ortiz A, Parati G, Rossignol P, Tripepi G, Vanholder R, Wiecek A, London G. Validity of Vascular Calcification as a Screening Tool and as a Surrogate End Point in Clinical Research. Hypertension 2015; 66:3-9. [PMID: 25966492 DOI: 10.1161/hypertensionaha.115.04801] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 04/16/2015] [Indexed: 12/16/2022]
Affiliation(s)
- Carmine Zoccali
- From the CNR-IFC Pathophysiology of Renal Diseases and Hypertension Unit, Reggio Calabria, Italy (C.Z., D.B., G.D'A., F.M., G.T.); Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands (F.W.D.); Department of Internal Medicine IV, Saarland University Medical Centre, Homburg/Saar, Germany (D.F., G.H.H.); Department of Medical Informatics, Academic Medical Center, European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry, University of Amsterdam, Amsterdam, The Netherlands (K.J.J.); Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey (M.K.); Nephrology, Dialysis, and Transplantation Unit and CNR-IFC Clinical Epidemiology, Reggio Calabria, Italy (F.M.); Paris Ile de France Ouest (UVSQ) University, Paris, France (Z.M.); Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Fundación Renal Iñigo Alvarez de Toledo, Madrid, Spain (A.O.); Department of Cardiovascular, Neural, and Metabolic Sciences, S. Luca Hospital, Istituto Auxologico Italiano & University of Milan-Bicocca, Milan, Italy (G.P.); INSERM, Centre d'Investigations Cliniques-Plurithématique 1433, INSERM U1116, Nancy, France (P.R.); Département de Cardiologie, CHU Nancy, Institut Lorrain du Cœur et des Vaisseaux, Vandoeuvre lès Nancy, France (P.R.); Université de Lorraine, Nancy, France (P.R.); INI-CRCT (Cardiovascular and Renal Clinical Trialists), French-Clinical Research Infrastructure Network (F-CRIN), Nancy, France (P.R.); Division of Nephrology, Department of Internal Medicine, Ghent University Hospital, University Hospital Gent, Ghent, Belgium (R.V.); Department of Nephrology, Endocrinology and Metabolic Diseases, Medical University of Silesia, Katowice, Poland (A.W.); and INSERM U970, Hopital Européen Georges Pompidou, Paris, France (G.L.).
| | - Davide Bolignano
- From the CNR-IFC Pathophysiology of Renal Diseases and Hypertension Unit, Reggio Calabria, Italy (C.Z., D.B., G.D'A., F.M., G.T.); Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands (F.W.D.); Department of Internal Medicine IV, Saarland University Medical Centre, Homburg/Saar, Germany (D.F., G.H.H.); Department of Medical Informatics, Academic Medical Center, European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry, University of Amsterdam, Amsterdam, The Netherlands (K.J.J.); Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey (M.K.); Nephrology, Dialysis, and Transplantation Unit and CNR-IFC Clinical Epidemiology, Reggio Calabria, Italy (F.M.); Paris Ile de France Ouest (UVSQ) University, Paris, France (Z.M.); Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Fundación Renal Iñigo Alvarez de Toledo, Madrid, Spain (A.O.); Department of Cardiovascular, Neural, and Metabolic Sciences, S. Luca Hospital, Istituto Auxologico Italiano & University of Milan-Bicocca, Milan, Italy (G.P.); INSERM, Centre d'Investigations Cliniques-Plurithématique 1433, INSERM U1116, Nancy, France (P.R.); Département de Cardiologie, CHU Nancy, Institut Lorrain du Cœur et des Vaisseaux, Vandoeuvre lès Nancy, France (P.R.); Université de Lorraine, Nancy, France (P.R.); INI-CRCT (Cardiovascular and Renal Clinical Trialists), French-Clinical Research Infrastructure Network (F-CRIN), Nancy, France (P.R.); Division of Nephrology, Department of Internal Medicine, Ghent University Hospital, University Hospital Gent, Ghent, Belgium (R.V.); Department of Nephrology, Endocrinology and Metabolic Diseases, Medical University of Silesia, Katowice, Poland (A.W.); and INSERM U970, Hopital Européen Georges Pompidou, Paris, France (G.L.)
| | - Graziella D'Arrigo
- From the CNR-IFC Pathophysiology of Renal Diseases and Hypertension Unit, Reggio Calabria, Italy (C.Z., D.B., G.D'A., F.M., G.T.); Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands (F.W.D.); Department of Internal Medicine IV, Saarland University Medical Centre, Homburg/Saar, Germany (D.F., G.H.H.); Department of Medical Informatics, Academic Medical Center, European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry, University of Amsterdam, Amsterdam, The Netherlands (K.J.J.); Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey (M.K.); Nephrology, Dialysis, and Transplantation Unit and CNR-IFC Clinical Epidemiology, Reggio Calabria, Italy (F.M.); Paris Ile de France Ouest (UVSQ) University, Paris, France (Z.M.); Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Fundación Renal Iñigo Alvarez de Toledo, Madrid, Spain (A.O.); Department of Cardiovascular, Neural, and Metabolic Sciences, S. Luca Hospital, Istituto Auxologico Italiano & University of Milan-Bicocca, Milan, Italy (G.P.); INSERM, Centre d'Investigations Cliniques-Plurithématique 1433, INSERM U1116, Nancy, France (P.R.); Département de Cardiologie, CHU Nancy, Institut Lorrain du Cœur et des Vaisseaux, Vandoeuvre lès Nancy, France (P.R.); Université de Lorraine, Nancy, France (P.R.); INI-CRCT (Cardiovascular and Renal Clinical Trialists), French-Clinical Research Infrastructure Network (F-CRIN), Nancy, France (P.R.); Division of Nephrology, Department of Internal Medicine, Ghent University Hospital, University Hospital Gent, Ghent, Belgium (R.V.); Department of Nephrology, Endocrinology and Metabolic Diseases, Medical University of Silesia, Katowice, Poland (A.W.); and INSERM U970, Hopital Européen Georges Pompidou, Paris, France (G.L.)
| | - Friedo W Dekker
- From the CNR-IFC Pathophysiology of Renal Diseases and Hypertension Unit, Reggio Calabria, Italy (C.Z., D.B., G.D'A., F.M., G.T.); Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands (F.W.D.); Department of Internal Medicine IV, Saarland University Medical Centre, Homburg/Saar, Germany (D.F., G.H.H.); Department of Medical Informatics, Academic Medical Center, European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry, University of Amsterdam, Amsterdam, The Netherlands (K.J.J.); Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey (M.K.); Nephrology, Dialysis, and Transplantation Unit and CNR-IFC Clinical Epidemiology, Reggio Calabria, Italy (F.M.); Paris Ile de France Ouest (UVSQ) University, Paris, France (Z.M.); Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Fundación Renal Iñigo Alvarez de Toledo, Madrid, Spain (A.O.); Department of Cardiovascular, Neural, and Metabolic Sciences, S. Luca Hospital, Istituto Auxologico Italiano & University of Milan-Bicocca, Milan, Italy (G.P.); INSERM, Centre d'Investigations Cliniques-Plurithématique 1433, INSERM U1116, Nancy, France (P.R.); Département de Cardiologie, CHU Nancy, Institut Lorrain du Cœur et des Vaisseaux, Vandoeuvre lès Nancy, France (P.R.); Université de Lorraine, Nancy, France (P.R.); INI-CRCT (Cardiovascular and Renal Clinical Trialists), French-Clinical Research Infrastructure Network (F-CRIN), Nancy, France (P.R.); Division of Nephrology, Department of Internal Medicine, Ghent University Hospital, University Hospital Gent, Ghent, Belgium (R.V.); Department of Nephrology, Endocrinology and Metabolic Diseases, Medical University of Silesia, Katowice, Poland (A.W.); and INSERM U970, Hopital Européen Georges Pompidou, Paris, France (G.L.)
| | - Danilo Fliser
- From the CNR-IFC Pathophysiology of Renal Diseases and Hypertension Unit, Reggio Calabria, Italy (C.Z., D.B., G.D'A., F.M., G.T.); Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands (F.W.D.); Department of Internal Medicine IV, Saarland University Medical Centre, Homburg/Saar, Germany (D.F., G.H.H.); Department of Medical Informatics, Academic Medical Center, European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry, University of Amsterdam, Amsterdam, The Netherlands (K.J.J.); Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey (M.K.); Nephrology, Dialysis, and Transplantation Unit and CNR-IFC Clinical Epidemiology, Reggio Calabria, Italy (F.M.); Paris Ile de France Ouest (UVSQ) University, Paris, France (Z.M.); Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Fundación Renal Iñigo Alvarez de Toledo, Madrid, Spain (A.O.); Department of Cardiovascular, Neural, and Metabolic Sciences, S. Luca Hospital, Istituto Auxologico Italiano & University of Milan-Bicocca, Milan, Italy (G.P.); INSERM, Centre d'Investigations Cliniques-Plurithématique 1433, INSERM U1116, Nancy, France (P.R.); Département de Cardiologie, CHU Nancy, Institut Lorrain du Cœur et des Vaisseaux, Vandoeuvre lès Nancy, France (P.R.); Université de Lorraine, Nancy, France (P.R.); INI-CRCT (Cardiovascular and Renal Clinical Trialists), French-Clinical Research Infrastructure Network (F-CRIN), Nancy, France (P.R.); Division of Nephrology, Department of Internal Medicine, Ghent University Hospital, University Hospital Gent, Ghent, Belgium (R.V.); Department of Nephrology, Endocrinology and Metabolic Diseases, Medical University of Silesia, Katowice, Poland (A.W.); and INSERM U970, Hopital Européen Georges Pompidou, Paris, France (G.L.)
| | - Gunnar H Heine
- From the CNR-IFC Pathophysiology of Renal Diseases and Hypertension Unit, Reggio Calabria, Italy (C.Z., D.B., G.D'A., F.M., G.T.); Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands (F.W.D.); Department of Internal Medicine IV, Saarland University Medical Centre, Homburg/Saar, Germany (D.F., G.H.H.); Department of Medical Informatics, Academic Medical Center, European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry, University of Amsterdam, Amsterdam, The Netherlands (K.J.J.); Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey (M.K.); Nephrology, Dialysis, and Transplantation Unit and CNR-IFC Clinical Epidemiology, Reggio Calabria, Italy (F.M.); Paris Ile de France Ouest (UVSQ) University, Paris, France (Z.M.); Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Fundación Renal Iñigo Alvarez de Toledo, Madrid, Spain (A.O.); Department of Cardiovascular, Neural, and Metabolic Sciences, S. Luca Hospital, Istituto Auxologico Italiano & University of Milan-Bicocca, Milan, Italy (G.P.); INSERM, Centre d'Investigations Cliniques-Plurithématique 1433, INSERM U1116, Nancy, France (P.R.); Département de Cardiologie, CHU Nancy, Institut Lorrain du Cœur et des Vaisseaux, Vandoeuvre lès Nancy, France (P.R.); Université de Lorraine, Nancy, France (P.R.); INI-CRCT (Cardiovascular and Renal Clinical Trialists), French-Clinical Research Infrastructure Network (F-CRIN), Nancy, France (P.R.); Division of Nephrology, Department of Internal Medicine, Ghent University Hospital, University Hospital Gent, Ghent, Belgium (R.V.); Department of Nephrology, Endocrinology and Metabolic Diseases, Medical University of Silesia, Katowice, Poland (A.W.); and INSERM U970, Hopital Européen Georges Pompidou, Paris, France (G.L.)
| | - Kitty J Jager
- From the CNR-IFC Pathophysiology of Renal Diseases and Hypertension Unit, Reggio Calabria, Italy (C.Z., D.B., G.D'A., F.M., G.T.); Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands (F.W.D.); Department of Internal Medicine IV, Saarland University Medical Centre, Homburg/Saar, Germany (D.F., G.H.H.); Department of Medical Informatics, Academic Medical Center, European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry, University of Amsterdam, Amsterdam, The Netherlands (K.J.J.); Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey (M.K.); Nephrology, Dialysis, and Transplantation Unit and CNR-IFC Clinical Epidemiology, Reggio Calabria, Italy (F.M.); Paris Ile de France Ouest (UVSQ) University, Paris, France (Z.M.); Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Fundación Renal Iñigo Alvarez de Toledo, Madrid, Spain (A.O.); Department of Cardiovascular, Neural, and Metabolic Sciences, S. Luca Hospital, Istituto Auxologico Italiano & University of Milan-Bicocca, Milan, Italy (G.P.); INSERM, Centre d'Investigations Cliniques-Plurithématique 1433, INSERM U1116, Nancy, France (P.R.); Département de Cardiologie, CHU Nancy, Institut Lorrain du Cœur et des Vaisseaux, Vandoeuvre lès Nancy, France (P.R.); Université de Lorraine, Nancy, France (P.R.); INI-CRCT (Cardiovascular and Renal Clinical Trialists), French-Clinical Research Infrastructure Network (F-CRIN), Nancy, France (P.R.); Division of Nephrology, Department of Internal Medicine, Ghent University Hospital, University Hospital Gent, Ghent, Belgium (R.V.); Department of Nephrology, Endocrinology and Metabolic Diseases, Medical University of Silesia, Katowice, Poland (A.W.); and INSERM U970, Hopital Européen Georges Pompidou, Paris, France (G.L.)
| | - Mehmet Kanbay
- From the CNR-IFC Pathophysiology of Renal Diseases and Hypertension Unit, Reggio Calabria, Italy (C.Z., D.B., G.D'A., F.M., G.T.); Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands (F.W.D.); Department of Internal Medicine IV, Saarland University Medical Centre, Homburg/Saar, Germany (D.F., G.H.H.); Department of Medical Informatics, Academic Medical Center, European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry, University of Amsterdam, Amsterdam, The Netherlands (K.J.J.); Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey (M.K.); Nephrology, Dialysis, and Transplantation Unit and CNR-IFC Clinical Epidemiology, Reggio Calabria, Italy (F.M.); Paris Ile de France Ouest (UVSQ) University, Paris, France (Z.M.); Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Fundación Renal Iñigo Alvarez de Toledo, Madrid, Spain (A.O.); Department of Cardiovascular, Neural, and Metabolic Sciences, S. Luca Hospital, Istituto Auxologico Italiano & University of Milan-Bicocca, Milan, Italy (G.P.); INSERM, Centre d'Investigations Cliniques-Plurithématique 1433, INSERM U1116, Nancy, France (P.R.); Département de Cardiologie, CHU Nancy, Institut Lorrain du Cœur et des Vaisseaux, Vandoeuvre lès Nancy, France (P.R.); Université de Lorraine, Nancy, France (P.R.); INI-CRCT (Cardiovascular and Renal Clinical Trialists), French-Clinical Research Infrastructure Network (F-CRIN), Nancy, France (P.R.); Division of Nephrology, Department of Internal Medicine, Ghent University Hospital, University Hospital Gent, Ghent, Belgium (R.V.); Department of Nephrology, Endocrinology and Metabolic Diseases, Medical University of Silesia, Katowice, Poland (A.W.); and INSERM U970, Hopital Européen Georges Pompidou, Paris, France (G.L.)
| | - Francesca Mallamaci
- From the CNR-IFC Pathophysiology of Renal Diseases and Hypertension Unit, Reggio Calabria, Italy (C.Z., D.B., G.D'A., F.M., G.T.); Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands (F.W.D.); Department of Internal Medicine IV, Saarland University Medical Centre, Homburg/Saar, Germany (D.F., G.H.H.); Department of Medical Informatics, Academic Medical Center, European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry, University of Amsterdam, Amsterdam, The Netherlands (K.J.J.); Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey (M.K.); Nephrology, Dialysis, and Transplantation Unit and CNR-IFC Clinical Epidemiology, Reggio Calabria, Italy (F.M.); Paris Ile de France Ouest (UVSQ) University, Paris, France (Z.M.); Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Fundación Renal Iñigo Alvarez de Toledo, Madrid, Spain (A.O.); Department of Cardiovascular, Neural, and Metabolic Sciences, S. Luca Hospital, Istituto Auxologico Italiano & University of Milan-Bicocca, Milan, Italy (G.P.); INSERM, Centre d'Investigations Cliniques-Plurithématique 1433, INSERM U1116, Nancy, France (P.R.); Département de Cardiologie, CHU Nancy, Institut Lorrain du Cœur et des Vaisseaux, Vandoeuvre lès Nancy, France (P.R.); Université de Lorraine, Nancy, France (P.R.); INI-CRCT (Cardiovascular and Renal Clinical Trialists), French-Clinical Research Infrastructure Network (F-CRIN), Nancy, France (P.R.); Division of Nephrology, Department of Internal Medicine, Ghent University Hospital, University Hospital Gent, Ghent, Belgium (R.V.); Department of Nephrology, Endocrinology and Metabolic Diseases, Medical University of Silesia, Katowice, Poland (A.W.); and INSERM U970, Hopital Européen Georges Pompidou, Paris, France (G.L.)
| | - Ziad Massy
- From the CNR-IFC Pathophysiology of Renal Diseases and Hypertension Unit, Reggio Calabria, Italy (C.Z., D.B., G.D'A., F.M., G.T.); Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands (F.W.D.); Department of Internal Medicine IV, Saarland University Medical Centre, Homburg/Saar, Germany (D.F., G.H.H.); Department of Medical Informatics, Academic Medical Center, European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry, University of Amsterdam, Amsterdam, The Netherlands (K.J.J.); Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey (M.K.); Nephrology, Dialysis, and Transplantation Unit and CNR-IFC Clinical Epidemiology, Reggio Calabria, Italy (F.M.); Paris Ile de France Ouest (UVSQ) University, Paris, France (Z.M.); Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Fundación Renal Iñigo Alvarez de Toledo, Madrid, Spain (A.O.); Department of Cardiovascular, Neural, and Metabolic Sciences, S. Luca Hospital, Istituto Auxologico Italiano & University of Milan-Bicocca, Milan, Italy (G.P.); INSERM, Centre d'Investigations Cliniques-Plurithématique 1433, INSERM U1116, Nancy, France (P.R.); Département de Cardiologie, CHU Nancy, Institut Lorrain du Cœur et des Vaisseaux, Vandoeuvre lès Nancy, France (P.R.); Université de Lorraine, Nancy, France (P.R.); INI-CRCT (Cardiovascular and Renal Clinical Trialists), French-Clinical Research Infrastructure Network (F-CRIN), Nancy, France (P.R.); Division of Nephrology, Department of Internal Medicine, Ghent University Hospital, University Hospital Gent, Ghent, Belgium (R.V.); Department of Nephrology, Endocrinology and Metabolic Diseases, Medical University of Silesia, Katowice, Poland (A.W.); and INSERM U970, Hopital Européen Georges Pompidou, Paris, France (G.L.)
| | - Alberto Ortiz
- From the CNR-IFC Pathophysiology of Renal Diseases and Hypertension Unit, Reggio Calabria, Italy (C.Z., D.B., G.D'A., F.M., G.T.); Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands (F.W.D.); Department of Internal Medicine IV, Saarland University Medical Centre, Homburg/Saar, Germany (D.F., G.H.H.); Department of Medical Informatics, Academic Medical Center, European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry, University of Amsterdam, Amsterdam, The Netherlands (K.J.J.); Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey (M.K.); Nephrology, Dialysis, and Transplantation Unit and CNR-IFC Clinical Epidemiology, Reggio Calabria, Italy (F.M.); Paris Ile de France Ouest (UVSQ) University, Paris, France (Z.M.); Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Fundación Renal Iñigo Alvarez de Toledo, Madrid, Spain (A.O.); Department of Cardiovascular, Neural, and Metabolic Sciences, S. Luca Hospital, Istituto Auxologico Italiano & University of Milan-Bicocca, Milan, Italy (G.P.); INSERM, Centre d'Investigations Cliniques-Plurithématique 1433, INSERM U1116, Nancy, France (P.R.); Département de Cardiologie, CHU Nancy, Institut Lorrain du Cœur et des Vaisseaux, Vandoeuvre lès Nancy, France (P.R.); Université de Lorraine, Nancy, France (P.R.); INI-CRCT (Cardiovascular and Renal Clinical Trialists), French-Clinical Research Infrastructure Network (F-CRIN), Nancy, France (P.R.); Division of Nephrology, Department of Internal Medicine, Ghent University Hospital, University Hospital Gent, Ghent, Belgium (R.V.); Department of Nephrology, Endocrinology and Metabolic Diseases, Medical University of Silesia, Katowice, Poland (A.W.); and INSERM U970, Hopital Européen Georges Pompidou, Paris, France (G.L.)
| | - Gianfranco Parati
- From the CNR-IFC Pathophysiology of Renal Diseases and Hypertension Unit, Reggio Calabria, Italy (C.Z., D.B., G.D'A., F.M., G.T.); Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands (F.W.D.); Department of Internal Medicine IV, Saarland University Medical Centre, Homburg/Saar, Germany (D.F., G.H.H.); Department of Medical Informatics, Academic Medical Center, European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry, University of Amsterdam, Amsterdam, The Netherlands (K.J.J.); Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey (M.K.); Nephrology, Dialysis, and Transplantation Unit and CNR-IFC Clinical Epidemiology, Reggio Calabria, Italy (F.M.); Paris Ile de France Ouest (UVSQ) University, Paris, France (Z.M.); Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Fundación Renal Iñigo Alvarez de Toledo, Madrid, Spain (A.O.); Department of Cardiovascular, Neural, and Metabolic Sciences, S. Luca Hospital, Istituto Auxologico Italiano & University of Milan-Bicocca, Milan, Italy (G.P.); INSERM, Centre d'Investigations Cliniques-Plurithématique 1433, INSERM U1116, Nancy, France (P.R.); Département de Cardiologie, CHU Nancy, Institut Lorrain du Cœur et des Vaisseaux, Vandoeuvre lès Nancy, France (P.R.); Université de Lorraine, Nancy, France (P.R.); INI-CRCT (Cardiovascular and Renal Clinical Trialists), French-Clinical Research Infrastructure Network (F-CRIN), Nancy, France (P.R.); Division of Nephrology, Department of Internal Medicine, Ghent University Hospital, University Hospital Gent, Ghent, Belgium (R.V.); Department of Nephrology, Endocrinology and Metabolic Diseases, Medical University of Silesia, Katowice, Poland (A.W.); and INSERM U970, Hopital Européen Georges Pompidou, Paris, France (G.L.)
| | - Patrick Rossignol
- From the CNR-IFC Pathophysiology of Renal Diseases and Hypertension Unit, Reggio Calabria, Italy (C.Z., D.B., G.D'A., F.M., G.T.); Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands (F.W.D.); Department of Internal Medicine IV, Saarland University Medical Centre, Homburg/Saar, Germany (D.F., G.H.H.); Department of Medical Informatics, Academic Medical Center, European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry, University of Amsterdam, Amsterdam, The Netherlands (K.J.J.); Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey (M.K.); Nephrology, Dialysis, and Transplantation Unit and CNR-IFC Clinical Epidemiology, Reggio Calabria, Italy (F.M.); Paris Ile de France Ouest (UVSQ) University, Paris, France (Z.M.); Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Fundación Renal Iñigo Alvarez de Toledo, Madrid, Spain (A.O.); Department of Cardiovascular, Neural, and Metabolic Sciences, S. Luca Hospital, Istituto Auxologico Italiano & University of Milan-Bicocca, Milan, Italy (G.P.); INSERM, Centre d'Investigations Cliniques-Plurithématique 1433, INSERM U1116, Nancy, France (P.R.); Département de Cardiologie, CHU Nancy, Institut Lorrain du Cœur et des Vaisseaux, Vandoeuvre lès Nancy, France (P.R.); Université de Lorraine, Nancy, France (P.R.); INI-CRCT (Cardiovascular and Renal Clinical Trialists), French-Clinical Research Infrastructure Network (F-CRIN), Nancy, France (P.R.); Division of Nephrology, Department of Internal Medicine, Ghent University Hospital, University Hospital Gent, Ghent, Belgium (R.V.); Department of Nephrology, Endocrinology and Metabolic Diseases, Medical University of Silesia, Katowice, Poland (A.W.); and INSERM U970, Hopital Européen Georges Pompidou, Paris, France (G.L.)
| | - Giovanni Tripepi
- From the CNR-IFC Pathophysiology of Renal Diseases and Hypertension Unit, Reggio Calabria, Italy (C.Z., D.B., G.D'A., F.M., G.T.); Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands (F.W.D.); Department of Internal Medicine IV, Saarland University Medical Centre, Homburg/Saar, Germany (D.F., G.H.H.); Department of Medical Informatics, Academic Medical Center, European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry, University of Amsterdam, Amsterdam, The Netherlands (K.J.J.); Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey (M.K.); Nephrology, Dialysis, and Transplantation Unit and CNR-IFC Clinical Epidemiology, Reggio Calabria, Italy (F.M.); Paris Ile de France Ouest (UVSQ) University, Paris, France (Z.M.); Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Fundación Renal Iñigo Alvarez de Toledo, Madrid, Spain (A.O.); Department of Cardiovascular, Neural, and Metabolic Sciences, S. Luca Hospital, Istituto Auxologico Italiano & University of Milan-Bicocca, Milan, Italy (G.P.); INSERM, Centre d'Investigations Cliniques-Plurithématique 1433, INSERM U1116, Nancy, France (P.R.); Département de Cardiologie, CHU Nancy, Institut Lorrain du Cœur et des Vaisseaux, Vandoeuvre lès Nancy, France (P.R.); Université de Lorraine, Nancy, France (P.R.); INI-CRCT (Cardiovascular and Renal Clinical Trialists), French-Clinical Research Infrastructure Network (F-CRIN), Nancy, France (P.R.); Division of Nephrology, Department of Internal Medicine, Ghent University Hospital, University Hospital Gent, Ghent, Belgium (R.V.); Department of Nephrology, Endocrinology and Metabolic Diseases, Medical University of Silesia, Katowice, Poland (A.W.); and INSERM U970, Hopital Européen Georges Pompidou, Paris, France (G.L.)
| | - Raymond Vanholder
- From the CNR-IFC Pathophysiology of Renal Diseases and Hypertension Unit, Reggio Calabria, Italy (C.Z., D.B., G.D'A., F.M., G.T.); Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands (F.W.D.); Department of Internal Medicine IV, Saarland University Medical Centre, Homburg/Saar, Germany (D.F., G.H.H.); Department of Medical Informatics, Academic Medical Center, European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry, University of Amsterdam, Amsterdam, The Netherlands (K.J.J.); Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey (M.K.); Nephrology, Dialysis, and Transplantation Unit and CNR-IFC Clinical Epidemiology, Reggio Calabria, Italy (F.M.); Paris Ile de France Ouest (UVSQ) University, Paris, France (Z.M.); Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Fundación Renal Iñigo Alvarez de Toledo, Madrid, Spain (A.O.); Department of Cardiovascular, Neural, and Metabolic Sciences, S. Luca Hospital, Istituto Auxologico Italiano & University of Milan-Bicocca, Milan, Italy (G.P.); INSERM, Centre d'Investigations Cliniques-Plurithématique 1433, INSERM U1116, Nancy, France (P.R.); Département de Cardiologie, CHU Nancy, Institut Lorrain du Cœur et des Vaisseaux, Vandoeuvre lès Nancy, France (P.R.); Université de Lorraine, Nancy, France (P.R.); INI-CRCT (Cardiovascular and Renal Clinical Trialists), French-Clinical Research Infrastructure Network (F-CRIN), Nancy, France (P.R.); Division of Nephrology, Department of Internal Medicine, Ghent University Hospital, University Hospital Gent, Ghent, Belgium (R.V.); Department of Nephrology, Endocrinology and Metabolic Diseases, Medical University of Silesia, Katowice, Poland (A.W.); and INSERM U970, Hopital Européen Georges Pompidou, Paris, France (G.L.)
| | - Andrzej Wiecek
- From the CNR-IFC Pathophysiology of Renal Diseases and Hypertension Unit, Reggio Calabria, Italy (C.Z., D.B., G.D'A., F.M., G.T.); Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands (F.W.D.); Department of Internal Medicine IV, Saarland University Medical Centre, Homburg/Saar, Germany (D.F., G.H.H.); Department of Medical Informatics, Academic Medical Center, European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry, University of Amsterdam, Amsterdam, The Netherlands (K.J.J.); Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey (M.K.); Nephrology, Dialysis, and Transplantation Unit and CNR-IFC Clinical Epidemiology, Reggio Calabria, Italy (F.M.); Paris Ile de France Ouest (UVSQ) University, Paris, France (Z.M.); Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Fundación Renal Iñigo Alvarez de Toledo, Madrid, Spain (A.O.); Department of Cardiovascular, Neural, and Metabolic Sciences, S. Luca Hospital, Istituto Auxologico Italiano & University of Milan-Bicocca, Milan, Italy (G.P.); INSERM, Centre d'Investigations Cliniques-Plurithématique 1433, INSERM U1116, Nancy, France (P.R.); Département de Cardiologie, CHU Nancy, Institut Lorrain du Cœur et des Vaisseaux, Vandoeuvre lès Nancy, France (P.R.); Université de Lorraine, Nancy, France (P.R.); INI-CRCT (Cardiovascular and Renal Clinical Trialists), French-Clinical Research Infrastructure Network (F-CRIN), Nancy, France (P.R.); Division of Nephrology, Department of Internal Medicine, Ghent University Hospital, University Hospital Gent, Ghent, Belgium (R.V.); Department of Nephrology, Endocrinology and Metabolic Diseases, Medical University of Silesia, Katowice, Poland (A.W.); and INSERM U970, Hopital Européen Georges Pompidou, Paris, France (G.L.)
| | - Gerard London
- From the CNR-IFC Pathophysiology of Renal Diseases and Hypertension Unit, Reggio Calabria, Italy (C.Z., D.B., G.D'A., F.M., G.T.); Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands (F.W.D.); Department of Internal Medicine IV, Saarland University Medical Centre, Homburg/Saar, Germany (D.F., G.H.H.); Department of Medical Informatics, Academic Medical Center, European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry, University of Amsterdam, Amsterdam, The Netherlands (K.J.J.); Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey (M.K.); Nephrology, Dialysis, and Transplantation Unit and CNR-IFC Clinical Epidemiology, Reggio Calabria, Italy (F.M.); Paris Ile de France Ouest (UVSQ) University, Paris, France (Z.M.); Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Fundación Renal Iñigo Alvarez de Toledo, Madrid, Spain (A.O.); Department of Cardiovascular, Neural, and Metabolic Sciences, S. Luca Hospital, Istituto Auxologico Italiano & University of Milan-Bicocca, Milan, Italy (G.P.); INSERM, Centre d'Investigations Cliniques-Plurithématique 1433, INSERM U1116, Nancy, France (P.R.); Département de Cardiologie, CHU Nancy, Institut Lorrain du Cœur et des Vaisseaux, Vandoeuvre lès Nancy, France (P.R.); Université de Lorraine, Nancy, France (P.R.); INI-CRCT (Cardiovascular and Renal Clinical Trialists), French-Clinical Research Infrastructure Network (F-CRIN), Nancy, France (P.R.); Division of Nephrology, Department of Internal Medicine, Ghent University Hospital, University Hospital Gent, Ghent, Belgium (R.V.); Department of Nephrology, Endocrinology and Metabolic Diseases, Medical University of Silesia, Katowice, Poland (A.W.); and INSERM U970, Hopital Européen Georges Pompidou, Paris, France (G.L.)
| | | |
Collapse
|
27
|
Floege J, Kubo Y, Floege A, Chertow GM, Parfrey PS. The Effect of Cinacalcet on Calcific Uremic Arteriolopathy Events in Patients Receiving Hemodialysis: The EVOLVE Trial. Clin J Am Soc Nephrol 2015; 10:800-7. [PMID: 25887067 DOI: 10.2215/cjn.10221014] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 12/07/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND OBJECTIVES Uncontrolled secondary hyperparathyroidism (sHPT) in patients with ESRD is a risk factor for calcific uremic arteriolopathy (CUA; calciphylaxis). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Adverse event reports collected during the Evaluation of Cinacalcet HCl Therapy to Lower Cardiovascular Events trial were used to determine the frequency of CUA in patients receiving hemodialysis who had moderate to severe sHPT, as well as the effects of cinacalcet versus placebo. CUA events were collected while patients were receiving the study drug. RESULTS Among the 3861 trial patients who received at least one dose of the study drug, 18 patients randomly assigned to placebo and six assigned to cinacalcet developed CUA (unadjusted relative hazard, 0.31; 95% confidence interval [95% CI], 0.13 to 0.79; P=0.014). Corresponding cumulative event rates (95% CI) at year 4 were 0.011% (0.006% to 0.018%) and 0.005% (0.002% to 0.010%). By multivariable analysis, other factors associated with CUA included female sex, higher body mass index, higher diastolic BP, and history of dyslipidemia or parathyroidectomy. Median (10%, 90% percentile) plasma parathyroid hormone concentrations proximal to the report of CUA were 796 (225, 2093) pg/ml and 410 (71, 4957) pg/ml in patients randomly assigned to placebo and cinacalcet, respectively. Active use of vitamin K antagonists was recorded in 11 of 24 patients with CUA, nine randomly assigned to placebo, and two to cinacalcet, in contrast to 5%-7% at any one time point in patients in whom CUA was not reported. CONCLUSION Cinacalcet appeared to reduce the incidence of CUA in hemodialysis recipients who have moderate to severe sHPT.
Collapse
Affiliation(s)
- Jürgen Floege
- Division of Nephrology, RWTH University of Aachen, Aachen, Germany;
| | - Yumi Kubo
- Amgen Inc., Thousand Oaks, California
| | - Anna Floege
- Division of Nephrology, RWTH University of Aachen, Aachen, Germany
| | - Glenn M Chertow
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California; and
| | - Patrick S Parfrey
- Department of Medicine, Memorial University, St. John's, Newfoundland, Canada
| |
Collapse
|
28
|
Kubo Y, Sterling LR, Parfrey PS, Gill K, Mahaffey KW, Gioni I, Trotman ML, Dehmel B, Chertow GM. Assessing the treatment effect in a randomized controlled trial with extensive non-adherence: the EVOLVE trial. Pharm Stat 2015; 14:242-51. [PMID: 25851955 DOI: 10.1002/pst.1680] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 01/15/2015] [Accepted: 03/06/2015] [Indexed: 11/06/2022]
Abstract
Intention-to-treat (ITT) analysis is widely used to establish efficacy in randomized clinical trials. However, in a long-term outcomes study where non-adherence to study drug is substantial, the on-treatment effect of the study drug may be underestimated using the ITT analysis. The analyses presented herein are from the EVOLVE trial, a double-blind, placebo-controlled, event-driven cardiovascular outcomes study conducted to assess whether a treatment regimen including cinacalcet compared with placebo in addition to other conventional therapies reduces the risk of mortality and major cardiovascular events in patients receiving hemodialysis with secondary hyperparathyroidism. Pre-specified sensitivity analyses were performed to assess the impact of non-adherence on the estimated effect of cinacalcet. These analyses included lag-censoring, inverse probability of censoring weights (IPCW), rank preserving structural failure time model (RPSFTM) and iterative parameter estimation (IPE). The relative hazard (cinacalcet versus placebo) of mortality and major cardiovascular events was 0.93 (95% confidence interval 0.85, 1.02) using the ITT analysis; 0.85 (0.76, 0.95) using lag-censoring analysis; 0.81 (0.70, 0.92) using IPCW; 0.85 (0.66, 1.04) using RPSFTM and 0.85 (0.75, 0.96) using IPE. These analyses, while not providing definitive evidence, suggest that the intervention may have an effect while subjects are receiving treatment. The ITT method remains the established method to evaluate efficacy of a new treatment; however, additional analyses should be considered to assess the on-treatment effect when substantial non-adherence to study drug is expected or observed.
Collapse
|
29
|
Parfrey PS, Drüeke TB, Block GA, Correa-Rotter R, Floege J, Herzog CA, London GM, Mahaffey KW, Moe SM, Wheeler DC, Kubo Y, Dehmel B, Goodman WG, Chertow GM. The Effects of Cinacalcet in Older and Younger Patients on Hemodialysis: The Evaluation of Cinacalcet HCl Therapy to Lower Cardiovascular Events (EVOLVE) Trial. Clin J Am Soc Nephrol 2015; 10:791-9. [PMID: 25710802 DOI: 10.2215/cjn.07730814] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Accepted: 01/20/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The calcimimetic cinacalcet reduced the risk of death or cardiovascular (CV) events in older, but not younger, patients with moderate to severe secondary hyperparathyroidism (HPT) who were receiving hemodialysis. To determine whether the lower risk in younger patients might be due to lower baseline CV risk and more frequent use of cointerventions that reduce parathyroid hormone (kidney transplantation, parathyroidectomy, and commercial cinacalcet use), this study examined the effects of cinacalcet in older (≥65 years, n=1005) and younger (<65 years, n=2878) patients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Evaluation of Cinacalcet HCl Therapy to Lower Cardiovascular Events (EVOLVE) was a global, multicenter, randomized placebo-controlled trial in 3883 prevalent patients on hemodialysis, whose outcomes included death, major CV events, and development of severe unremitting HPT. The age subgroup analysis was prespecified. RESULTS Older patients had higher baseline prevalence of diabetes mellitus and CV comorbidity. Annualized rates of kidney transplantation and parathyroidectomy were >3-fold higher in younger relative to older patients and were more frequent in patients randomized to placebo. In older patients, the adjusted relative hazard (95% confidence interval) for the primary composite (CV) end point (cinacalcet versus placebo) was 0.70 (0.60 to 0.81); in younger patients, the relative hazard was 0.97 (0.86 to 1.09). Corresponding adjusted relative hazards for mortality were 0.68 (0.51 to 0.81) and 0.99 (0.86 to 1.13). Reduction in the risk of severe unremitting HPT was similar in both groups. CONCLUSIONS In the EVOLVE trial, cinacalcet decreased the risk of death and of major CV events in older, but not younger, patients with moderate to severe HPT who were receiving hemodialysis. Effect modification by age may be partly explained by differences in underlying CV risk and differential application of cointerventions that reduce parathyroid hormone.
Collapse
Affiliation(s)
- Patrick S Parfrey
- Department of Medicine, Health Sciences Center, St. John's, Newfoundland, Canada;
| | - Tilman B Drüeke
- French Institute of Health and Medical Research Unit 1088, Faculty of Medicine and Pharmacy, University of Picardie, Amiens, France
| | | | - Ricardo Correa-Rotter
- Department of Nephrology and Mineral Metabolism, Salvador Zubirán National Institute of Health Sciences and Nutrition, Mexico City, Mexico
| | - Jürgen Floege
- Department of Nephrology, RWTH Aachen University Hospital, Aachen, Germany
| | - Charles A Herzog
- Department of Internal Medicine, University of Minnesota, Minneapolis, Minnesota
| | | | - Kenneth W Mahaffey
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Sharon M Moe
- Department of Medicine, Indiana University School of Medicine and Roudebush Veterans Administration Medical Center, Indianapolis, Indiana
| | - David C Wheeler
- Centre for Nephrology, University College London, United Kingdom; and
| | - Yumi Kubo
- Amgen Inc, Thousand Oaks, California
| | | | | | - Glenn M Chertow
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | | |
Collapse
|
30
|
Parfrey PS. Randomized controlled trials 6: On contamination and estimating the actual treatment effect. Methods Mol Biol 2015; 1281:249-59. [PMID: 25694314 DOI: 10.1007/978-1-4939-2428-8_14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The intention-to-treat analysis is the gold standard for evaluating efficacy in a randomized controlled trial. However, when non-adherence to randomized treatments is high, the actual treatment effect may be underestimated. The impact of drop-out from the intervention group or drop-in to the control group may be controlled by trial design, increasing the sample size, effective study execution, and a prespecified analytical plan to take contamination into account. These analyses may include censoring at time of co-interventions associated with stopping treatment, lag censoring which allows an additional period after discontinuation of study treatment to account for residual treatment effects, inverse probability of censoring weights (IPCW), accelerated failure time models, and contamination adjusted intent-to-treat analysis. These methods are particularly useful in assessing the "prescribed efficacy" of the study treatment, which can aid clinical decision-making.
Collapse
Affiliation(s)
- Patrick S Parfrey
- Faculty of Medicine, Memorial University of Newfoundland, Room H1420, 300 Prince Philip Drive, St. John's, NL, Canada, A1B 3V6,
| |
Collapse
|
31
|
Ballinger AE, Palmer SC, Nistor I, Craig JC, Strippoli GFM. Calcimimetics for secondary hyperparathyroidism in chronic kidney disease patients. Cochrane Database Syst Rev 2014; 2014:CD006254. [PMID: 25490118 PMCID: PMC10614033 DOI: 10.1002/14651858.cd006254.pub2] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Calcimimetic agents lower abnormal serum parathyroid hormone (PTH) levels in people who have chronic kidney disease (CKD), but the benefits and harms on patient-level outcomes are uncertain. Since this review was first published in 2006 showing that evidence for calcimimetics was largely restricted to biochemical outcomes, additional studies have been conducted. This is an update of a review first published in 2006. OBJECTIVES To evaluate the benefits and harms of cinacalcet on patient-level outcomes in adults with CKD. SEARCH METHODS MEDLINE, EMBASE, CENTRAL and conference proceedings were searched for randomised controlled trials (RCTs) evaluating any calcimimetic against placebo or another agent in adults with CKD (persistent albuminuria > 30 mg/g with or without reduced glomerular filtration rate (GFR) (below 60 mL/min/1.73 m²)). We updated searches to 7 February 2013 including the Cochrane Renal Group's Specialised Register to complete this update. SELECTION CRITERIA We included all RCTs of a calcimimetic administered to patients with CKD for the treatment of elevated serum PTH levels. DATA COLLECTION AND ANALYSIS Data were extracted on all relevant patient-centred and surrogate outcomes. We summarised treatment estimates using random effects and expressed treatment effects as a risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI). MAIN RESULTS Eighteen studies (7446 participants) compared cinacalcet in addition to standard therapy with no treatment or placebo plus standard therapy. In adults with GFR category G5 (GFR below 15 mL/min/1.73 m²) treated with dialysis, routine cinacalcet treatment had little or no effect on all-cause mortality (RR 0.97, 95% CI 0.89 to 1.05), imprecise effects on cardiovascular mortality (RR 0.67, 95% CI 0.16 to 2.87), and prevented surgical parathyroidectomy (RR 0.49, 95% CI 0.40 to 0.59) and hypercalcaemia (RR 0.23, 95% CI 0.05 to 0.97), but increased hypocalcaemia (RR 6.98, 95% CI 5.10 to 9.53), nausea (RR 2.02, 95% CI 1.45 to 2.81) and vomiting (RR 1.97, 95% CI 95% CI 1.73 to 2.24). Cinacalcet decreased serum PTH (MD -281.39 pg/mL, 95% CI -325.84 to -234.94) and calcium (MD -0.87 mg/dL, 95% CI -0.96 to -0.77) levels, but had little or no effect on serum phosphorous levels (MD -0.23 mg/dL, 95% CI -0.58 to 0.12).Data were sparse for adults with GFR categories G3a to G4 (GFR 15 to 60 mL/min/1.73 m²) and kidney transplant recipients.Overall, based on GRADE criteria, evidence for cinacalcet in adults with GFR category G5 treated with dialysis (mortality, parathyroidectomy, hypocalcaemia, and nausea) is of high or moderate quality. High quality evidence suggests "further research is very unlikely to change our confidence in the estimate of treatment effect" and moderate quality evidence is "further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate". Information for adults with less severe CKD GFR category G3a to G4 is of low or very low quality. This means that further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate AUTHORS' CONCLUSIONS Routine cinacalcet therapy reduced the need for parathyroidectomy in adults treated with dialysis and elevated PTH levels but does not improve all-cause or cardiovascular mortality. Cinacalcet increases risks of nausea, vomiting and hypocalcaemia, suggesting harms may outweigh benefits in this population.
Collapse
Affiliation(s)
- Angela E Ballinger
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AveChristchurchNew Zealand8041
| | - Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AveChristchurchNew Zealand8041
| | - Ionut Nistor
- "Gr. T. Popa" University of Medicine and PharmacyNephrology DepartmentBdul Carol I, No 50IasiIasiRomania700503
- Ghent University HospitalEuropean Renal Best Practice Methods Support TeamGhentBelgium
| | - Jonathan C Craig
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | - Giovanni FM Strippoli
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchWestmeadNSWAustralia2145
- University of BariDepartment of Emergency and Organ TransplantationBariItaly70100
- Mario Negri Sud ConsortiumDepartment of Clinical Pharmacology and EpidemiologySanta Maria ImbaroItaly
- DiaverumMedical‐Scientific OfficeLundSweden
- Amedeo Avogadro University of Eastern PiedmontDivision of Nephrology and Transplantation, Department of Translational MedicineNovaraItaly28100
| | | |
Collapse
|
32
|
Wheeler DC, London GM, Parfrey PS, Block GA, Correa-Rotter R, Dehmel B, Drüeke TB, Floege J, Kubo Y, Mahaffey KW, Goodman WG, Moe SM, Trotman ML, Abdalla S, Chertow GM, Herzog CA. Effects of cinacalcet on atherosclerotic and nonatherosclerotic cardiovascular events in patients receiving hemodialysis: the EValuation Of Cinacalcet HCl Therapy to Lower CardioVascular Events (EVOLVE) trial. J Am Heart Assoc 2014; 3:e001363. [PMID: 25404192 PMCID: PMC4338730 DOI: 10.1161/jaha.114.001363] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background Premature cardiovascular disease limits the duration and quality of life on long‐term hemodialysis. The objective of this study was to define the frequency of fatal and nonfatal cardiovascular events attributable to atherosclerotic and nonatherosclerotic mechanisms, risk factors for these events, and the effects of cinacalcet, using adjudicated data collected during the EValuation of Cinacalcet HCl Therapy to Lower CardioVascular Events (EVOLVE) Trial. Methods and Results EVOLVE was a randomized, double‐blind, placebo‐controlled clinical trial that randomized 3883 hemodialysis patients with moderate to severe secondary hyperparathyroidism to cinacalcet or matched placebo for up to 64 months. For this post hoc analysis, the outcome measure was fatal and nonfatal cardiovascular events reflecting atherosclerotic and nonatherosclerotic cardiovascular diseases. During the trial, 1518 patients experienced an adjudicated cardiovascular event, including 958 attributable to nonatherosclerotic disease. Of 1421 deaths during the trial, 768 (54%) were due to cardiovascular disease. Sudden death was the most frequent fatal cardiovascular event, accounting for 24.5% of overall mortality. Combining fatal and nonfatal cardiovascular events, randomization to cinacalcet reduced the rates of sudden death and heart failure. Patients randomized to cinacalcet experienced fewer nonatherosclerotic cardiovascular events (adjusted relative hazard 0.84, 95% CI 0.74 to 0.96), while the effect of cinacalcet on atherosclerotic events did not reach statistical significance. Conclusions Accepting the limitations of post hoc analysis, any benefits of cinacalcet on cardiovascular disease in the context of hemodialysis may result from attenuation of nonatherosclerotic processes. Clinical Trials Registration Unique identifier: NCT00345839. URL: ClinicalTrials.gov.
Collapse
Affiliation(s)
| | | | | | | | - Ricardo Correa-Rotter
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico (R.C.R.)
| | - Bastian Dehmel
- Amgen, Inc, Thousand Oaks, CA (B.D., Y.K., W.G.G., M.L.T.)
| | - Tilman B Drüeke
- Inserm Unit 1088, UFR Médecine/Pharmacie, Université de Picardie, Amiens, France (T.B.D.)
| | - Jürgen Floege
- Universitätsklinikum der RWTH Aachen, Aachen, Germany (F.)
| | - Yumi Kubo
- Amgen, Inc, Thousand Oaks, CA (B.D., Y.K., W.G.G., M.L.T.)
| | - Kenneth W Mahaffey
- Stanford University School of Medicine, Palo Alto, CA (K.W.M., S.A., G.M.C.)
| | | | - Sharon M Moe
- Indiana University School of Medicine, Roudebush Veterans Administration Medical Center, Indianapolis, IN (S.M.M.)
| | | | - Safa Abdalla
- Stanford University School of Medicine, Palo Alto, CA (K.W.M., S.A., G.M.C.)
| | - Glenn M Chertow
- Stanford University School of Medicine, Palo Alto, CA (K.W.M., S.A., G.M.C.)
| | - Charles A Herzog
- Hennepin County Medical Center, University of Minnesota, Minneapolis, MN (C.A.H.)
| | | |
Collapse
|
33
|
Parfrey PS, Chertow GM, Block GA, Correa-Rotter R, Drüeke TB, Floege J, Herzog CA, London GM, Mahaffey KW, Moe SM, Wheeler DC, Dehmel B, Trotman ML, Modafferi DM, Goodman WG. The clinical course of treated hyperparathyroidism among patients receiving hemodialysis and the effect of cinacalcet: the EVOLVE trial. J Clin Endocrinol Metab 2013; 98:4834-44. [PMID: 24108314 DOI: 10.1210/jc.2013-2975] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT The clinical course of secondary hyperparathyroidism (sHPT) in patients on hemodialysis is not well described, and the effect of the calcimimetic cinacalcet on disease progression is uncertain. OBJECTIVE Our objective was to describe 1) the clinical course of sHPT in patients treated with phosphate binders and/or vitamin D sterols and 2) the impact of cinacalcet on the occurrence of severe unremitting HPT, defined by the persistence of markedly elevated PTH concentrations together with hypercalcemia or parathyroidectomy (PTX). DESIGN AND SETTING This was a randomized, double-blind, placebo-controlled, global, multicenter clinical trial. PATIENTS Of 5755 patients screened with moderate to severe sHPT, 3883 patients on hemodialysis were included in the trial. MAIN OUTCOME MEASURES Outcomes included PTX; severe, unremitting HPT; and use of commercial cinacalcet (a protocol violation). INTERVENTION Intervention was cinacalcet (30-180 mg daily) or placebo for up to 64 months. RESULTS In the 1935 patients randomized to placebo, 278 patients (14%) underwent PTX (median PTH 1872 pg/mL within the previous 12 weeks from surgery). Age, sex, geographic region, co-morbidity, calcium-containing phosphate binder use, and baseline serum calcium, phosphorus, and PTH concentrations were associated with PTX. Commercial cinacalcet was started in 443 (23%) patients (median PTH 1108 pg/mL before treatment began). Severe unremitting HPT developed in 470 patients (24%). In a multivariable Cox model, the relative hazard (comparing patients randomized to cinacalcet versus placebo) of severe unremitting HPT was 0.31 (95% confidence interval = 0.26-0.37). The relative hazard differed little when adjusted by baseline clinical characteristics. CONCLUSIONS Severe unremitting HPT develops frequently in patients on hemodialysis despite conventional therapy, and cinacalcet substantially reduces its occurrence.
Collapse
Affiliation(s)
- Patrick S Parfrey
- MD, Health Sciences Center, Memorial University, St John's, Newfoundland, Canada A1B 3V6.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Moe SM, Thadhani R. What have we learned about chronic kidney disease-mineral bone disorder from the EVOLVE and PRIMO trials? Curr Opin Nephrol Hypertens 2013; 22:651-5. [PMID: 24100218 PMCID: PMC3983668 DOI: 10.1097/mnh.0b013e328365b3a3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE OF REVIEW The treatment of chronic kidney disease-mineral bone disorder (CKD-MBD) has traditionally focused on improvement in biochemical parameters of the disease. However, studies evaluating hard clinical end points or surrogate end points are limited. RECENT FINDINGS Two randomized controlled trials have recently been published. In the EVOLVE study (Evaluation of Cinacalcet Hydrochloride Therapy to Lower Cardiovascular Events), cinacalcet was compared with placebo in 3883 haemodialysis patients with secondary hyperparathyroidism. The primary end point (death, myocardial infarction, unstable angina, heart failure or peripheral vascular disease) in an unadjusted intention-to-treat analysis was not significant [hazard ratio 0.93; 95% confidence interval (CI) 0.85-1.02, P=0.11]. However, the pre-specified secondary end points of an adjusted intention-to-treat analysis (hazard ratio 0.88; 95% CI 0.79-0.97, P=0.008) were significant. In the PRIMO (Paricalcitol Capsule Benefits in Renal Failure Induced Cardiac Morbidity) trial, 227 patients with CKD stage 3-4 and left ventricular hypertrophy by echocardiography were randomized to paricalcitol or placebo. The primary end point of change in left ventricular mass index by MRI after 12 months was not different between the two groups, but the prespecified end point of cardiovascular-related hospitalizations was reduced in the paricalcitol-treated group (P=0.04). SUMMARY The results of these two randomized controlled trials have negative primary end points but significant secondary end points and thus require physicians to individualize therapies for the treatment of secondary hyperparathyroidism.
Collapse
Affiliation(s)
- Sharon M Moe
- aIndiana University School of Medicine and Roudebush Veterans Administration Medical Center, Indianapolis, Indiana bMassachusettes General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | |
Collapse
|
35
|
Fukagawa M, Yokoyama K, Koiwa F, Taniguchi M, Shoji T, Kazama JJ, Komaba H, Ando R, Kakuta T, Fujii H, Nakayama M, Shibagaki Y, Fukumoto S, Fujii N, Hattori M, Ashida A, Iseki K, Shigematsu T, Tsukamoto Y, Tsubakihara Y, Tomo T, Hirakata H, Akizawa T. Clinical Practice Guideline for the Management of Chronic Kidney Disease-Mineral and Bone Disorder. Ther Apher Dial 2013; 17:247-88. [DOI: 10.1111/1744-9987.12058] [Citation(s) in RCA: 251] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
36
|
A prospective randomized pilot study on intermittent post-dialysis dosing of cinacalcet. Int Urol Nephrol 2013; 46:113-9. [PMID: 23529273 DOI: 10.1007/s11255-013-0418-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 03/13/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND Treatment of secondary hyperparathyroidism (SHPT) is important in management of patients with end-stage renal disease on hemodialysis (HD). Calcimimetic agent, cinacalcet provides an option for control of SHPT in patients who fail traditional therapy. It may not have optimal results in non-compliant patients. To enhance compliance, we evaluated effectiveness of post-dialysis dosing of cinacalcet (group AD) as compared to daily home administration (group D) in a prospective randomized trial of HD patients with refractory SHPT. METHODS After 2-week run-in phase, patients were randomly assigned to two treatment groups. In group AD (N = 12), patients were administered cinacalcet on the day of dialysis (3 times/week) by dialysis staff, while in control group D (N = 11), cinacalcet was prescribed daily to be taken by patients at home. Intact parathyroid hormone (i-PTH), serum calcium, phosphorus, and alkaline phosphatase were followed for 16 weeks and compared to baseline in both groups. Data were analyzed using between-groups linear regression for repeated measures. RESULTS No significant decline in i-PTH occurred in group AD at 16 weeks as compared to a significant drop in group D (p = 0.006). However, subgroup analysis showed effectiveness of post-dialysis dosing in patients with less severe SHPT (p = 0.04). CONCLUSION Although daily dosing overall was more effective for treatment of SHPT, dialysis dosing was effective in patients with less severe SHPT. This warrants a larger study considering the limitations of this pilot trial. In the meantime, dialysis dosing can be considered in non-compliant patients with less severe SHPT.
Collapse
|
37
|
Sinha AK. Evolve trial. Indian Heart J 2013. [DOI: 10.1016/j.ihj.2013.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
|
38
|
Ureña-Torres P, Bridges I, Christiano C, Cournoyer SH, Cooper K, Farouk M, Kopyt NP, Rodriguez M, Zehnder D, Covic A. Efficacy of cinacalcet with low-dose vitamin D in incident haemodialysis subjects with secondary hyperparathyroidism. Nephrol Dial Transplant 2013; 28:1241-54. [PMID: 23328710 DOI: 10.1093/ndt/gfs568] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Treatment with cinacalcet improves the control of secondary hyperparathyroidism (SHPT) and the achievement of calcium and phosphorus targets. Most data come from subjects receiving cinacalcet after several years of dialysis treatment. We therefore compared the efficacy of treatment with cinacalcet and low doses of active vitamin D to flexible doses of active vitamin D alone for the management of SHPT in patients recently initiating haemodialysis. METHODS This open-label trial randomized subjects (n = 309) with parathyroid hormone (PTH) >300 pg/mL on dialysis for 3-12 months to either cinacalcet with low-dose active vitamin D, if prescribed (cinacalcet); or usual care without cinacalcet (control). Randomized subjects were stratified by PTH at screening (300-450, >450-600, >600 pg/mL) and by the use of active vitamin D at enrolment. Treatment duration was 12 months, with primary efficacy endpoint (mean PTH reduction ≥ 30% from baseline) assessed at 6 months. RESULTS The mean [standard deviation (SD)] haemodialysis vintage at enrolment was 7.2 (2.7) months; 53% of subjects were not receiving active vitamin D at enrolment. There was a significant difference in the achievement of the primary endpoint (≥ 30% PTH reduction at 6 months) between cinacalcet-treated subjects and controls in both the entire cohort (63 versus 38%; n = 304; P < 0.0001) and the subgroup of subjects not receiving active vitamin D at enrolment (70 versus 44%; n = 161; P < 0.01). Hypocalcaemia and gastrointestinal adverse events were more commonly observed in cinacalcet-treated subjects. CONCLUSIONS These results indicate that cinacalcet with low-dose active vitamin D, if prescribed, provides a more effective treatment approach than usual care without cinacalcet for SHPT in incident haemodialysis patients, even in relatively treatment-naive patients.
Collapse
|
39
|
Chertow GM, Block GA, Correa-Rotter R, Drüeke TB, Floege J, Goodman WG, Herzog CA, Kubo Y, London GM, Mahaffey KW, Mix TCH, Moe SM, Trotman ML, Wheeler DC, Parfrey PS. Effect of cinacalcet on cardiovascular disease in patients undergoing dialysis. N Engl J Med 2012; 367:2482-94. [PMID: 23121374 DOI: 10.1056/nejmoa1205624] [Citation(s) in RCA: 593] [Impact Index Per Article: 49.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Disorders of mineral metabolism, including secondary hyperparathyroidism, are thought to contribute to extraskeletal (including vascular) calcification among patients with chronic kidney disease. It has been hypothesized that treatment with the calcimimetic agent cinacalcet might reduce the risk of death or nonfatal cardiovascular events in such patients. METHODS In this clinical trial, we randomly assigned 3883 patients with moderate-to-severe secondary hyperparathyroidism (median level of intact parathyroid hormone, 693 pg per milliliter [10th to 90th percentile, 363 to 1694]) who were undergoing hemodialysis to receive either cinacalcet or placebo. All patients were eligible to receive conventional therapy, including phosphate binders, vitamin D sterols, or both. The patients were followed for up to 64 months. The primary composite end point was the time until death, myocardial infarction, hospitalization for unstable angina, heart failure, or a peripheral vascular event. The primary analysis was performed on the basis of the intention-to-treat principle. RESULTS The median duration of study-drug exposure was 21.2 months in the cinacalcet group, versus 17.5 months in the placebo group. The primary composite end point was reached in 938 of 1948 patients (48.2%) in the cinacalcet group and 952 of 1935 patients (49.2%) in the placebo group (relative hazard in the cinacalcet group vs. the placebo group, 0.93; 95% confidence interval, 0.85 to 1.02; P=0.11). Hypocalcemia and gastrointestinal adverse events were significantly more frequent in patients receiving cinacalcet. CONCLUSIONS In an unadjusted intention-to-treat analysis, cinacalcet did not significantly reduce the risk of death or major cardiovascular events in patients with moderate-to-severe secondary hyperparathyroidism who were undergoing dialysis. (Funded by Amgen; EVOLVE ClinicalTrials.gov number, NCT00345839.).
Collapse
|
40
|
|
41
|
Ariyamuthu VK, Balla S, Chaudhary K. Ischemic heart disease in patients undergoing dialysis. Hosp Pract (1995) 2012; 40:33-39. [PMID: 23299034 DOI: 10.3810/hp.2012.10.1001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Cardiovascular disease is the most common cause of death in patients with end-stage renal disease (ESRD) who are undergoing chronic dialysis. Diabetes and hypertension, the 2 leading causes of ESRD, contribute to the pathogenesis of ischemic heart disease (IHD) in these patients, as do other traditional risk factors (eg, dyslipidemias, smoking, and sedentary lifestyle). However, patients with ESRD are subject to several unique risk factors that contribute to the development and progression of IHD. Chronic volume overload and anemia, leading to left ventricular hypertrophy, and deranged calcium-phosphate metabolism with vascular and coronary calcification, contribute to the pathogenesis of IHD. Other risk factors that have been implicated include oxidative stress, homocysteine, and myocardial stunning while undergoing dialysis treatment. Additional risk factors include erythropoietin use for treating anemia, as well as use of calcium-based phosphate binders. The complex pathogenesis of IHD in such patients poses unique challenges to its management. Serological biomarkers and sophisticated imaging techniques are being developed to better delineate the pathological process and enhance disease detection. A combination of medical and surgical approaches is necessary to treat IHD. In this article, we discuss the pathogenesis and management of IHD.
Collapse
|
42
|
Yuan CM, Nee R, Narayan R, Abbott KC. Treatment of secondary hyperparathyroidism with parathyroidectomy instead of cinacalcet: time to pick the low-hanging fruit? Am J Kidney Dis 2012; 60:179-81. [PMID: 22805518 DOI: 10.1053/j.ajkd.2012.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Accepted: 05/11/2012] [Indexed: 11/11/2022]
|
43
|
Ureña P, Fouque D, Brunet P, Touam M, Réglier JC. [Cinacalcet treatment for secondary hyperparathyroidism in dialysis patients in real-world clinical practice - the ECHO observational study: French experience]. Nephrol Ther 2012; 8:527-33. [PMID: 23018042 DOI: 10.1016/j.nephro.2012.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Revised: 05/15/2012] [Accepted: 05/28/2012] [Indexed: 11/25/2022]
Abstract
UNLABELLED 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.
Collapse
Affiliation(s)
- P Ureña
- Néphrologie et dialyse, clinique du Landy, 23, rue du Landy, 93400 Saint-Ouen, France.
| | | | | | | | | |
Collapse
|
44
|
Current Concepts and Management Strategies in Chronic Kidney Disease-Mineral and Bone Disorder. South Med J 2012; 105:479-85. [DOI: 10.1097/smj.0b013e318261f7fe] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
45
|
Medical and Surgical Management (Including Diet). Clin Rev Bone Miner Metab 2012. [DOI: 10.1007/s12018-011-9116-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
|
46
|
Hyperphosphatemia - The Risk Factor for Adverse Outcome in Maintenance Hemodialysis Patients. J Med Biochem 2012. [DOI: 10.2478/v10011-012-0002-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Hyperphosphatemia - The Risk Factor for Adverse Outcome in Maintenance Hemodialysis PatientsHyperphosphatemia is a potent stimulator of vascular and valvular calcifications in hemodialysis patients. To determine the prevalence of hyperphosphatemia and assess its effect on the outcome of hemodialysis patients, a total of 115 chronic hemodialysis patients were studied. Laboratory parameters were determined at baseline, and after 12 and 24 months of follow-up. Valvular calcification was assessed with echocardiography. Laboratory parameters were statistically analyzed with ANOVA. Survival analysis was performed with the Kaplan-Meier test and Log-Rank test. Hyperphosphatemia was present in 31.30% of the patients, high calcium-phosphate (Ca × P) product in 36.52% and valvular calcifications in 48.70%. Patients with serum phosphate >2.10 mmol/L and Ca × P product >5.65 mmol2/L2at baseline were at high risk for all-cause and cardiovascular mortality. Hyperphosphatemia is a risk factor for adverse outcome in patients on regular hemodialysis.
Collapse
|
47
|
Abstract
Cardiovascular diseases such as coronary artery disease, congestive heart failure, arrhythmia, and sudden cardiac death represent the leading causes of morbidity and mortality in patients with CKD, increasing sharply as patients approach end-stage renal disease. The pathogenesis includes a complex, bidirectional interaction between the heart and kidneys that encompasses traditional and nontraditional risk factors, and has been termed cardio-renal syndrome type 4. In this review, an overview of the epidemiology and scope of this problem is provided, some suggested mechanisms for the pathophysiology of this disorder are discussed, and some of the key treatment strategies are described, with particular focus on recent clinical trials, both negative and positive.
Collapse
Affiliation(s)
- Andrew A House
- Schulich School of Medicine and Dentistry, University of Western Ontario Division of Nephrology, University Hospital, London, Ontario, Canada.
| |
Collapse
|
48
|
Komaba H, Moriwaki K, Goto S, Yamada S, Taniguchi M, Kakuta T, Kamae I, Fukagawa M. Cost-effectiveness of cinacalcet hydrochloride for hemodialysis patients with severe secondary hyperparathyroidism in Japan. Am J Kidney Dis 2012; 60:262-71. [PMID: 22445709 DOI: 10.1053/j.ajkd.2011.12.034] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Accepted: 12/30/2011] [Indexed: 11/11/2022]
Abstract
BACKGROUND Cinacalcet effectively reduces elevated levels of parathyroid hormone (PTH) in patients with secondary hyperparathyroidism (SHPT), even those with severe disease for whom parathyroidectomy can be the treatment of choice. The objective of this study was to estimate the cost-effectiveness of cinacalcet treatment in hemodialysis patients with severe SHPT in Japan. STUDY DESIGN Cost-effectiveness analysis. SETTING & POPULATION Patients with severe SHPT (intact PTH >500 pg/mL) who were receiving hemodialysis in Japan. MODEL, PERSPECTIVE, & TIMEFRAME A Markov model was constructed from the health care system perspective in Japan. Patients were followed up over their lifetime. Dialysis costs were not included in the base case. INTERVENTION Cinacalcet as an addition to conventional treatment compared to conventional treatment alone. In both arms, patients underwent parathyroidectomy if intact PTH level was >500 pg/mL for 6 months and they were eligible for surgery. OUTCOMES Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). RESULTS ICERs for cinacalcet for those who were eligible for surgery and those who were not were $352,631/QALY gained and $21,613/QALY gained, respectively. Sensitivity and scenario analyses showed that results were fairly robust to variations in model parameters and assumptions. In the probabilistic sensitivity analysis, cinacalcet was cost-effective in only 0.9% of simulations for those eligible for surgery, but in more than 99.9% of simulations for those ineligible for surgery, if society would be willing to pay $50,000 per additional QALY. LIMITATIONS Data for the long-term effect of cinacalcet on patient-level outcomes are limited. The model predicted rates for clinical events using data for the surrogate biochemical end points. CONCLUSIONS The use of cinacalcet to treat severe SHPT is likely to be cost-effective for only those who cannot undergo parathyroid surgery for medical or personal reasons.
Collapse
Affiliation(s)
- Hirotaka Komaba
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara, Japan
| | | | | | | | | | | | | | | |
Collapse
|
49
|
Torres PAU, De Broe M. Calcium-sensing receptor, calcimimetics, and cardiovascular calcifications in chronic kidney disease. Kidney Int 2012; 82:19-25. [PMID: 22437409 DOI: 10.1038/ki.2012.69] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Renal function impairment goes along with a disturbed calcium, phosphate, and vitamin D metabolism, resulting in secondary hyperparathyroidism (sHPT). These mineral metabolism disturbances are associated with soft tissue calcifications, particularly arteries, cardiac valves, and myocardium, ultimately associated with increased risk of mortality in patients with chronic kidney disease (CKD). sHPT may lead to cardiovascular calcifications by other mechanisms including an impaired effect of parathyroid hormone (PTH), and a decreased calcium-sensing receptor (CaR) expression on cardiovascular structures. PTH may play a direct role on vascular calcifications through activation of a receptor, the type-1 PTH/PTHrP receptor, normally attributed to PTH-related peptide (PTHrP). The CaR in vascular cells may also play a role on vascular mineralization as suggested by its extremely reduced expression in atherosclerotic calcified human arteries. Calcimimetic compounds increasing the CaR sensitivity to extracellular calcium efficiently reduce serum PTH, calcium, and phosphate in dialysis patients with sHPT. They upregulate the CaR in vascular cells and attenuate vascular mineralization in uremic states. In this article, the pathophysiological mechanisms associated with cardiovascular calcifications in case of sHPT, the impact of medical and surgical correction of sHPT, the biology of the CaR in vascular structures and its function in CKD state, and finally the role played by the CaR and its modulation by the calcimimetics on uremic-related cardiovascular calcifications are reviewed.
Collapse
|
50
|
Karohl C, Raggi P. Cinacalcet: will it play a role in reducing cardiovascular events? Future Cardiol 2012; 8:357-70. [PMID: 22420327 DOI: 10.2217/fca.11.82] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Secondary hyperparathyroidism is a common complication of chronic kidney disease and it is associated with high morbidity and mortality. It is characterized by high parathyroid hormone levels and bone turnover leading to bone pain, deformity and fragility. Furthermore, secondary hyperparathyroidism adversely affects the cardiovascular system and has been associated with cardiovascular calcification and cardiomyopathy. Cinacalcet, a type II calcimimetic, is an effective and well-tolerated oral therapy for the management of secondary hyperparathyroidism. It is an allosteric activator of the calcium-sensing receptor enhancing sensitivity of parathyroid cells to extracellular calcium, which leads to inhibition of parathyroid hormone secretion. The calcium-sensing receptor expression in cardiomyocytes, endothelial cells and vascular smooth muscle cells raises the possibility that this receptor may be implicated in the pathophysiology of cardiovascular disease and constitute a potential therapeutic target. This article reviews the role of the calcimimetic agent cinacalcet in the prevention and progression of cardiovascular calcification and uremic cardiomyopathy in the chronic kidney disease setting.
Collapse
Affiliation(s)
- Cristina Karohl
- Division of Cardiology & Department of Medicine, Emory University, 1365 Clifton Rd NE, AT-504, Atlanta, GA 30322, USA
| | | |
Collapse
|