Achieving K/DOQI Targets with Cinacalcet in Dialysis Patients with Secondary Hyperparathyroidism. A Portuguese Observational Study

Secondary hyperparathyroidism is a common complication of chronic kidney disease. The elevated serum intact parathyroid hormone, phosphorus, calcium and calcium x phosphorus product have been independently associated with an increased relative risk of mortality. The standard therapy for secondary hyperparathyroidism, including active vitamin D analogues and phosphate binders, is often insufficient to allow patients to achieve the recommended Kidney Disease Outcomes Quality Initiative targets for bone and mineral metabolism. Randomised controlled phase III clinical studies in chronic kidney disease patients with secondary hyperparathyroidism have shown that cinacalcet treatment increases the proportion of patients achieving the recommended Kidney Disease Outcomes Quality Initiative targets for intact parathyroid hormone, phosphorus, calcium and calcium x phosphorus product. Aims: This observational multicentre study aims to evaluate cinacalcet’s ability to achieve and maintain Kidney Disease Outcomes Quality Initiative targets in a population with secondary hyperparathyroidism on chronic haemodialysis in Portugal. Patients and Methods: Patients on chronic dialysis that received cinacalcet during a free sampling programme were enrolled. Retrospective and prospective monthly data were collected from 3 months before until 6 months after the beginning of cinacalcet treatment. Additional assessment included a 12 month evaluation of all parameters. Results: 140 dialysis patients with secondary hyperparathyroidism were enrolled, 60% male, mean age 57.4±14.1 years. The mean intact parathyroid hormone, calcium, phosphorus, and calcium x phosphorus product values at baseline were 751.7±498.8 pg/ml, 9.7±3.8 mg/dl, 5.5±1.5 mg/dl, and 52.7±25.3 mg2/dl2, respectively. After 6 months’ cinacalcet treatment, 26.2%, 53.6%, 59.3%, and 81.0% of the patients achieved the Kidney Disease Outcomes Quality Initiative recommended levels for intact parathyroid hormone, calcium, phosphorus, and calcium x phosphorus product, respectively. The mean dose of cinacalcet at 6 months was 57.1±29.7 mg/day. Conclusions: The use of cinacalcet in clinical practice is an effective option for the treatment of secondary hyperparathyroidism in chronic dialysis patients, allowing more patients to reach and maintain the Kidney Disease Outcomes Quality Initiative targets.

Clinical benefits of an adherence monitoring program in the management of secondary hyperparathyroidism with cinacalcet: results of a prospective randomized controlled study.

BACKGROUND/AIMS: One of the causes of uncontrolled secondary hyperparathyroidism (sHPT) is patient's poor drug adherence. We evaluated the clinical benefits of an integrated care approach on the control of sHPT by cinacalcet. METHODS: Prospective, randomized, controlled, multicenter, open-label study. Fifty hemodialysis patients on a stable dose of cinacalcet were randomized to an integrated care approach (IC) or usual care approach (UC). In the IC group, cinacalcet adherence was monitored using an electronic system. Results were discussed with the patients in motivational interviews, and drug prescription adapted accordingly. In the UC group, drug adherence was monitored, but results were not available. RESULTS: At six months, 84% of patients in the IC group achieved recommended iPTH targets versus 55% in the UC group (P = 0.04). The mean cinacalcet taking adherence improved by 10.8% in the IC group and declined by 5.3% in the UC group (P = 0.02). Concomitantly, the mean dose of cinacalcet was reduced by 7.2 mg/day in the IC group and increased by 6.4 mg/day in the UC group (P = 0.03). CONCLUSIONS: The use of a drug adherence monitoring program in the management of sHPT in hemodialysis patients receiving cinacalcet improves drug adherence and iPTH control and allows a reduction in the dose of cinacalcet.

Place de ta vitamine D, du sevelamer et du cinacalcet dans la prise en charge des patients en insuffisance rénale [Treatment of secondary hyperparathyroidism in renal insufficiency: role of calcitriol, sevelamer and cinacalcet]

Along with the decrease in kidney function arises a secondary hyperparathyroidism, which constitutes one of the most important risk factor for mortality in patients suffering from renal insufficiency. Treating secondary hyperparathyroidism is challenging, as most of the parameters of mineral metabolism are interconnected. We review here the pathophysiology and treatment options of this entity.

Eficacia clínica del Cinacalcet en hiperparatiroidismo primario

Objetivos: Realizar una revisión sistemática para evaluar la eficacia y seguridad del Cinacalcet en el control del calcio sérico y paratohormona en los pacientes con hiperparatiroidismo primario leve a moderado. Metodología: se realizó una revisión sistemática de la literatura, en las bases de datos de Pubmed, Cochrane, Embase, Clinical Trials tesis internacionales y publicaciones Iberolatinoamericana de artículos desde el 2002 hasta junio del 2014, en inglés y español, así como búsqueda secundaria en artículos de revisión. Resultados: Se incluyeron 7 estudios en la revisión (dos ensayos clínicos aleatorizados y cinco estudios abiertos), demostrando una disminución de -1,25 (-1,5, -1,01) (p<0,00001) del calcio sérico con el uso del Cinacalcet al compararlo con placebo. La disminución de la PTH fue inconsistente, al reportar una disminución significativa de la PTH sólo en un estudio; tampoco se observaron cambios en la densidad mineral ósea. Los efectos adversos reportados en los ECA reportaron RR= 0,86 (0,41-1,72). La hipocalcemia fue encontrada en 5 de los 6 estudios, respondiendo universalmente al ajuste del fármaco. Conclusiones: Se encontró una reducción del calcio sérico a niveles normales, sin cambios significativos en la PTH y en la densidad mineral ósea en pacientes con hiperparatiroidismo primario. Respecto a la seguridad no se encontraron efectos adversos serios, sin embargo las variables de mortalidad, reducción del riesgo de fracturas y el riesgo cardiovascular no ha sido adecuadamente evaluado en el hiperparatiroidismo primario.

Effect of cinacalcet cessation in renal transplant recipients with persistent hyperparathyroidism

BACKGROUND: Persistent hyperparathyroidism after renal transplantation affects bone and allografts. Cinacalcet, a calcimimetic, reduces serum calcium and PTH in renal transplant recipients with persistent hyperparathyroidism. Here, we address the question whether this effect of cinacalcet persists after withdrawal. METHODS: Therefore, cinacalcet was stopped after 12 months treatment in 10 stable renal transplant patients. Serum calcium, phosphate, PTH, creatinine and cystatin C were monitored for 3 months. RESULTS: Serum calcium, normalized in nine patients before cessation of cinacalcet (2.32 +/- 0.05mmol/l, mean +/- SEM), increased after 3 months of discontinuation by 0.17 +/- 0.04mmol/l, P < 0.05, but remained within the normal range in eight patients. Compared with the time point of cessation, PTH remained unchanged or decreased further after 3 months without therapy in six patients. Measurements of cystatin C suggested an improvement of the glomerular filtration rate after cessation in 9 out of 10 patients (1.55 +/- 0.09 vs 1.33 +/- 0.12 mg/l, P < 0.01). CONCLUSION: First, a beneficial effect of cinacalcet beyond the duration of a 12-month therapy appears to be present in some patients and second, the previously suspected influence of cinacalcet therapy on renal function is reversible. Thus, it is reasonable to consider a trial of cinacalcet cessation to identify these patients. The optimal time point for such a discontinuation is unknown. The present observations are preliminary. They clearly require a prospective randomized trial for definitive confirmation.

Mineral and Bone Disease (MBD) on a Kidney Transplant Patient

A 50-year-old post-menopausal recipient of a kidney allograft with bone pain, osteoporosis, persistent hypercalcaemia and elevated parathormone (PTH) levels, despite a satisfactory graft function, was treated with bisphosphonates and cinacalcet starting, respectively, 5 and 6 months after renal transplantation (RT). Sixteen months after treatment, there was improvement of bone mineral density (BMD) measured by dualenergy X-ray absorptiometry (DEXA). A bone biopsy was taken, unveiling a surprising and worrisome result. Post-RT bone disease is different from classic CKD-MBD and should be managed distinctly, including, in some difficult cases, an invasive evaluation through the performance of a bone biopsy, as suggested in the KDIGO guidelines.

Improvement in secondary hyperparathyroidism due to drug adherence monitoring in dialysis patients.

BACKGROUND: Poor medication adherence is a frequent cause of treatment failure but is difficult to diagnose. In this study we have evaluated the impact of measuring adherence to cinacalcet-HCl and phosphate binders in dialysis patients with uncontrolled secondary hyperparathyroidism. METHODS: 7 chronic dialysis patients with iPTH-levels >= 300 pg/ml despite treatment with >= 60 mg cinacalcet-HCl were included. Medication adherence was measured using the "Medication Events Monitoring System" during 3 months, followed by another 3-month period without monitoring. The adherence results were monthly discussed with the patients, as well as strategies to improve them. RESULTS: During monitoring, the percentage of prescribed doses taken was higher for cinacalcet-HCl (87.4%) and sevelamer (86.3%) than for calcium acetate (76.1%), as was the taking adherence (81.9% vs. 57.3% vs. 49.1%) but not the percentage of drug holidays (12.3% vs. 4.5% vs. 3.6%). Mean PO4 levels (from 2.24 +/- 0.6 mmol/l to 1.73 +/- 0.41 mmol/l; p = 0.14) and Ca++ x PO4 product (4.73 +/- 1.43 to 3.41 +/- 1.04 mmol2/l2; p = 0.12) improved and iPTH-level improved significantly from 916 +/- 618 pg/ml to 442 +/- 326 pg/ml (p = 0.04), without any change in medication. However, as drug monitoring was interrupted, all laboratory parameters worsened again. CONCLUSIONS: Assessment of drug adherence helped to document episodes of non-compliance and helped to avoid seemingly necessary dose increases.

Furosemide stimulation of parathormone in humans: role of the calcium-sensing receptor and the renin-angiotensin system.

Interactions between sodium and calcium regulating systems are poorly characterized but clinically important. Parathyroid hormone (PTH) levels are increased shortly after furosemide treatment by an unknown mechanism, and this effect is blunted by the previous administration of a calcimimetic in animal studies. Here, we explored further the possible underlying mechanisms of this observation in a randomized crossover placebo-controlled study performed in 18 human males. Volunteers took either cinacalcet (60 mg) or placebo and received a 20 mg furosemide injection 3 h later. Plasma samples were collected at 15-min intervals and analyzed for intact PTH, calcium, sodium, potassium, magnesium, phosphate, plasma renin activity (PRA), and aldosterone up to 6 h after furosemide injection. Urinary electrolyte excretion was also monitored. Subjects under placebo presented a sharp increase in PTH levels after furosemide injection. In the presence of cinacalcet, PTH levels were suppressed and marginal increase of PTH was observed. No significant changes in electrolytes and urinary excretion were identified that could explain the furosemide-induced increase in PTH levels. PRA and aldosterone were stimulated by furosemide injection but were not affected by previous cinacalcet ingestion. Expression of NKCC1, but not NKCC2, was found in parathyroid tissue. In conclusion, our results indicate that furosemide acutely stimulates PTH secretion in the absence of any detectable electrolyte changes in healthy adults. A possible direct effect of furosemide on parathyroid gland needs further studies.

Furosemide stimulation of parathormone in humans: role of the calcium-sensing receptor and the renin-angiotensin system

Les interactions entre les systèmes de régulation du sodium et du calcium sont encore mal comprises et leur importance clinique mérite d'être étudiée plus en détail. Les études chez l'animal ont montré qu'il existe des relations entre le taux plasmatique d'hormone parathyroïdienne (PTH) et l'aldostérone ou l'activité de la rénine. Par ailleurs, il a été démontré chez l'animal et chez l'homme que le taux sanguin de PTH augmente rapidement après une injection de furosémide, un diurétique de l'anse ce qui fait penser qu'il existe un lien entre l'effet du furosémide sur le rein et la sécrétion de PTH. Toutefois, à ce jour, le(s) mécanisme(s) impliqués dans ce lien reste(nt) encore inconnu(s). Des résultats plus récents suggèrent que l'effet du furosemide est amoindri par l'administration préalable d'un calcimimétique agissant au niveau du récepteur sensible au calcium (calcium sensing receptor). Pour explorer chez l'homme, les mécanismes possibles du lien entre PTH et effet du furosemide sur le rein, nous avons planifié une étude randomisée croisée contre placebo réalisée chez 18 volontaires sains masculins. Le but principal était d'investiguer le rôle du système rénine-angiotensine et des calcium sensing receptors. L'étude s'est donc réalisée en 2 phases pour chaque sujet. Les participants ont ainsi reçu soit du cinacalcet (60mg) soit un placebo dans une première phase et le placebo ou du cinacalcet dans la 2° phase. Dans chaque phase d'évaluation, une injection de 20 mg de furosemide a été administrée par voie intraveineuse à l'équilibre soit 3 heures après la prise du placebo ou du cinacalcet. Des échantillons de plasma ont été prélevés toutes les 15 minutes pendant 1 heure puis toutes les heures pour le dosage de PTH intacte, calcium, sodium, potassium, magnésium, phosphate, activité de la rénine plasmatique et aldostérone jusqu'à 6h après l'injection de furosémide. L'excrétion urinaire de ces mêmes électrolytes a été mesurée aux mêmes intervalles.

Einfluss des Calcium-sensitiven Rezeptors auf knochenspezifische Metastasierungsprozesse des Nierenzellkarzinoms

Der Grund für die schlechte Prognose beim Nierenzellkarzinom (NZK) stellt nicht der Primärtumor dar sondern ist vielmehr der häufigen Ausbildung von Fernmetastasen geschuldet. Etwa 30 % aller Patienten mit fortgeschrittenem NZK bilden dabei Metastasen in den Knochen aus. Das Knochenmilieu scheint, aufgrund der hohen Frequenz der knochenspezifischen Metastasierung, einen idealen Wachstumslokus für die Nierenkarzinomzellen dazustellen und rückte in der jüngsten Vergangenheit in den Fokus der Forschung. Dabei konnte der Calcium-sensitive Rezeptor (CaSR), der im gesunden Gewebe die Konzentration der extrazellulären Calcium-Ionen reguliert und besonders in der Niere von Bedeutung ist, mit der Metastasierung in die Knochen in Zusammenhang gebracht werden. Die Knochen stellen im Körper das Organ mit der höchsten Calcium-Konzentration dar. Durch ständigen Knochenmetabolismus werden Calcium-Ionen freigesetzt, welche CaSR-exprimierende Zellen aktivieren können. Aus diesem Grund wurden im Zusammenhang mit dieser Arbeit Nierenkarzinomzellen (786 O) sowie gesunde Nierenzellen (HEK 293) mit dem Gen des CaSR transfiziert und anschließend unter dem Einfluss von Calcium (10 mM – 30 Min.), einem CaSR-Aktivator (Cinacalcet (10 µM – 1 Std.)), sowie einem CaSR-Inhibitor (NPS2143 (10 µM – 1 Std.)) auf Unterschiede im zellulären Verhalten hin untersucht.rnBereits ohne Calcium-Behandlung zeigten die CaSR-transfizierten 786 O-Zellen ein gesteigertes Migrationsverhalten (durchgeführt in einer Boyden Kammer, Fibronektin als Chemotaxin) und ein erhöhtes Adhäsionspotential (zum einen an Kompo¬nenten der EZM (Fibronektin und Kollagen I) und zum anderen an HUVEC). Bei den CaSR-transfizierten HEK 293-Zellen wurde nur die Migration positiv beeinflusst. Nach einer 30-minütigen Behandlung mit Calcium zeigten die CaSR-transfizierten 786 O-Zellen eine starke Zunahme des Adhäsions- und Proli¬ferations-verhaltens, sowie eine verstärkte Migration bei Verwendung von Calcium als Chemotaxin. CaSR-transfizierte HEK 293-Zellen hingegen zeigten keine Migration und nach Calcium-Behandlung nur geringfügige Änderungen in Adhäsion und Proliferation. Konsistent mit diesen Ergebnissen war die Auswertung der intrazellulären Signalwege mit Hilfe von Western Blot-Analysen. In CaSR-expri-mierenden 786 O-Zellen waren die Signalwege AKT, ERK, JNK und p38α nach Calcium-Behandlung deutlich erhöht. In den HEK 293-Zellen kam es zu einer Zunahme der Proteinmenge aktivierter ERK-, JNK-, Paxillin- und SHC-Moleküle. Mit Hilfe einer Kombinationsbehandlung aus NPS2143 und Calcium konnte der Calcium-bedingte Effekt in durchweg allen Untersuchungen wieder bis auf das Kontrollniveau gesenkt werden. Die Verwendung von Cinacalcet und Calcium führte zwar erneut zu deutlichen Steigerungen der zellulären Vorgänge, lag aber immer unter dem Calcium-abhängigen Maximum.rnDurch die Simulation der Vorgänge, die während einer Metastasierung ablaufen, konnte gezeigt werden, dass der CaSR in Nierenkarzinomzellen die Knochen-metastasierung induziert. Sollten sich diese Zusammenhänge in vivo im Mausmodell bestätigen, könnte der CaSR zukünftig als Marker für eine Früherkennung von Knochenmetastasen fungieren. Zudem könnten indivi¬dual¬isierte Therapieansätze entwickelt werden, die knochenmetastasierende Zellen bereits vor Metastasierung effizient bekämpfen können.rn

Characterization of bone pathologies in the ins2+/akita mouse, a new model for diabetes insulindependent: contribution for a better understanding of the disease in humans

Tese de Doutoramento, Ciências Biomédicas, Departamento de Ciências Biomédicas e Medicina, Universidade do Algarve, 2016