Calcific uremic arteriolopathy while on cinacalcet

The use of cinacalcet for the treatment of calciphylaxis in patients with chronic kidney disease: A comprehensive review

Calciphylaxis is a rare but life-threatening condition, most commonly affecting patients with stage 4 or 5 chronic kidney disease. No universally accepted therapy exists so far. In an attempt to avoid surgical intervention with parathyroidectomy, which is of questionable efficacy and carries several risks, a number of noninvasive treatments have been trialled with variable success. These treatments are aimed at modifying risk factors for calciphylaxis, in particular hypercalcaemia, hyperphosphataemia and hyperparathyroidism. The aim of this review was to summarise the available evidence to determine the potential role of cinacalcet in the treatment of calciphylaxis in patients with chronic kidney disease. Demographic, clinical and laboratory data were retrospectively collected from the available English and non-English literature. Overall, there was a very high response rate (partial or complete) of calciphylaxis lesions to both cinacalcet monotherapy and cinacalcet as part of a combination therapy (83.4% and 82.8%, respectively). When examining complete response to treatment specifically, combination therapy with cinacalcet proved more efficacious than monotherapy (62.1% versus 41.7%). There was also an associated rapid reduction of intact parathyroid hormone over a period of 2-33 months in both groups. While there are limitations as to how our data can be interpreted due to the heterogeneity of the methods and follow-up of the included case reports and case series, prompt and consistent therapy including cinacalcet may help improve the disease outcome. Additional research needs to be performed in this area, to further define the optimal use of cinacalcet for the treatment of calciphylaxis.

Multimodal treatment of calcific uraemic arteriolopathy (calciphylaxis): a case series

Background

This is an incident series of five dialysis patients with late-diagnosed calcific uraemic arteriolophathy (CUA), severe uncontrolled hyperparathyroidism and infected skin ulcerations.

Methods

A multimodal intervention was based on wound care, antibiotics, surgical debridement, sodium thiosulphate and cinacalcet and associated with regression of skin disease in four cases after varying treatment time periods ranging from 4 to 33 months.

Results

Multimodal treatment including sodium thiosulphate and cinacalcet was associated with very favourable local outcomes and survival. This series further confirms that the diagnosis of CUA is rarely made at the nodular, non-ulcerative phase of the disease.

Conclusions

This series contributes to the build-up of case series reporting on the treatment of CUA, and will hopefully serve as a basis of well-conceived comparative effectiveness studies investigating the value of the combined interventions applied so far in this severe condition.

Haemodialysate: long neglected, difficult to optimize, may modify hard outcomes

In two recent CKJ reviews, experts (Basile and Lomonte and Locatelli et al.) have reviewed haemodialysate composition. A long-neglected issue, observational studies have associated the composition of haemodialysate to adverse outcomes. However, the scarcity of clinical trial-derived information results in limited guideline recommendations on the issue. Indeed, guidelines have more frequently indicated what not to do rather than what to do. In this setting, expert opinion becomes invaluable. In designing haemodialysate composition, a balance should be struck between the need to correct within a time frame of around 4 hours the electrolyte and water imbalances that take 48 to 72 h to build, with the need for gradual correction of these imbalances. The issue is complicated further by the impact of individual variability in dietary habits, medications and comorbidities. In this regard, a personalized medicine approach to individualization of haemodialysate composition offers the best chance of improving patient outcomes. But how can haemodialysate individualization be achieved, and what clinical trial design will best test the impact of such approaches on patient outcomes?

Sodium thiosulfate therapy for calcific uremic arteriolopathy

BACKGROUND AND OBJECTIVE

Calcific uremic arteriolopathy (CUA) is an often fatal condition with no effective treatment. Multiple case reports and case series have described intravenous sodium thiosulfate (STS) administration in CUA, but no studies have systematically evaluated this treatment.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This study included 172 patients undergoing maintenance hemodialysis who had CUA and were treated with STS between August 2006 and June 2009 at Fresenius Medical Care North America. Of these, 85% completed STS therapy. Clinical, laboratory, and mortality data were abstracted from clinical information systems. Responses to survey questionnaires sent to treating physicians regarding patient-level outcomes were available for 53 patients. Effect on CUA lesions and mortality were summarized as CUA outcomes. Relevant laboratory measures, weight (using pairwise comparisons of values before, during, and after STS), and adverse events were summarized as safety parameters.

RESULTS

Mean age of the cohort was 55 years, and 74% of patients were women. Median STS dose was 25 g, and median number of doses was 38. Among surveyed patients, CUA completely resolved in 26.4%, markedly improved in 18.9%, improved in 28.3%, and did not improve in 5.7%; in the remaining patients (20.8%), the response was unknown. One-year mortality in patients treated with STS was 35%. Adverse events, laboratory abnormalities, and weight-related changes were mild. Significant reductions in serum phosphorous (P=0.02) and parathyroid hormone (P=0.01) were noted during STS treatment in patients who completed the therapy.

CONCLUSIONS

Although conclusive evidence regarding its efficacy is lacking, a majority of patients who received STS demonstrated clinical improvement in this study.