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Mineral Metabolism and Bone Disease |
* Departments of Medicine, Epidemiology and Biostatistics, University of California, San Francisco, School of Medicine, San Francisco, California; Centre Point RCG Dialysis Center, West Allis, Wisconsin; Amgen, Inc., Thousand Oaks, California; Renal Associates, Baton Rouge, Louisiana; || Columbia University, New York, New York; and ¶ Nephrology Associates PC, Columbus, Mississippi
Address correspondence to: Dr. Glenn M. Chertow, Department of Medicine Research, UCSF Laurel Heights, Suite 430, 3333 California Street, San Francisco, CA 94118. Phone: 415-476-2173; Fax: 415-476-9531; E-mail: chertowg{at}medicine.ucsf.edu
Active vitamin D derivatives attenuate the severity of secondary hyperparathyroidism but often increase serum calcium (Ca) and phosphorus (P) as a result of enhanced intestinal absorption. The calcimimetic cinacalcet HCl lowers parathyroid hormone (PTH) and tends to decrease Ca x P. A 16-wk, open-label clinical trial was conducted in adult hemodialysis patients who had controlled PTH (biointact PTH [biPTH] 80 to 160 pg/ml) and elevated Ca x P (>55 mg2/dl2) and were receiving paricalcitol >6 µg/wk (or an equipotent dose of an alternative active vitamin D derivative). At the start of the study, active vitamin D derivatives were decreased to a mean equivalent dose of paricalcitol 6 µg/wk, and cinacalcet was titrated from 30 mg/d to a maximum possible dose of 180 mg/d. Of the 72 study patients, 53 (74%) completed 8 wk of dose titration with cinacalcet. In response to cinacalcet, the following mean percentage changes were observed: biPTH, –1.8%; Ca, –9.7% (P < 0.0001), phosphorus, –11.1% (P < 0.0001), and Ca x P, –20.1% (P < 0.0001). At the end of the study, approximate Kidney Disease Outcomes Quality Initiative targets for biPTH (
160 pg/ml) were achieved in 85% (45 of 53) of patients and for Ca x P (55 mg2/dl2) in 72% (38 of 53) of patients. Concurrent achievement of both targets occurred in 47% (25 of 53) of patients. In this open-label clinical trial, hemodialysis patients who had controlled PTH but elevated Ca x P and were taking moderate- to high-dose active vitamin D derivatives achieved improved control of mineral metabolism with a combination of low-dose active vitamin D derivatives and cinacalcet. The long-term effects of this treatment regimen on clinical outcomes should be tested prospectively.
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