Lack or insufficient predialysis nephrology care worsens the outcomes in dialyzed patients - call for action.

The phenomenon of patients with advanced renal failure accepted for dialysis at a late stage in the disease process (late referral [LR]) is known almost from the beginning of dialysis therapy. It may also be associated with worse outcomes. The aim of the study was to assess the effect of referral time on the outcomes, such as number of hospitalizations, length of stay, kidney transplantation, and mortality. A study of 1303 patients with end-stage renal failure admitted for dialysis in the same period in Fresenius Nephrocare Poland dialysis centers was initiated. The type of vascular access during the first dialysis was accepted as the criterion differentiating LR (n = 457 with acute catheter) from early referral (ER; n = 846). The primary endpoint was the occurrence of death during the 13-month observation. By the end of observation, 341 (26.2%) of patients died. The frequency of death was 18.1 for ER and 37.9 for LR per 1000 patient-months. It can be estimated that 52.1% (95% CI: 40.5-61.5%) of the 341 deaths were caused by belonging to the LR group. Patients from LR group had longer hospitalizations, more malignancies, lower rate of vascular access in the form of a-v fistula, higher comorbidity index. It seems that establishing a nephrological registry would help to improve the organization of care for patients with kidney disease, particularly in the pandemic era.

Three Therapeutic Strategies: Cinacalcet, Paricalcitol or Both in Secondary Hyperparathyroidism Treatment in Hemodialysed Patients During 1-Year Observational Study-A Comparison.

Introduction: Secondary hyperparathyroidism (sHPT) is a common hormonal complication of chronic kidney disease. There are several therapeutic options for sHPT management aiming at calcium-phosphorus balance normalization and decrease of parathormone secretion. Objectives: The aim of this retrospective, observational study was the outcome assessement of three most common therapeutic strategies of secondary hyperparathyroidism treatment with vitamin D receptor activator-paricalcitol, calcimimetic-cinacalcet or both agents administered together during in 12-months period. Methods: One hundred and thirty-one haemodialysed patients with uncontrolled parathyroid hormone secretion have been treated with paricalcitol administered intravenously (group PAR-60 patients) or cinacalcet per os (group CIN-50 patients). The last group (group PAR+CIN-21 patients) received paricalcitol i.v. and oral cinacalcet administered simultaneously. Results: In all groups, the iPTH level decreased significantly, however in group 1 treated with paricalcitol administered intravenously iPTH level decrease was greater than in group 2 treated with cinacalcet and in group 3 treated with paricalcitol and cinacalcet in parallel. The most substantial change of iPTH level was noticed after 3-months of observation. After this period the iPTH level was stabilized and maintained till the end of observation. Safety level of all strategies was comparable. No severe hypercalcemia or hypocalcemia was observed during the whole period of observation. Conclusions: The results of observation show significant advantage of intravenous paricalcitol treatment. Complementing cinacalcet therapy with paricalcitol does not improve treatment outcomes. In case of unsatisfactory results after 3-months treatment, potential continuation should be considered carefully. Among three available therapeutic options, the treatment with paricalcitol i.v. should be considered in all haemodialysed patients with inadequate control of serum PTH level. The second option-with cinacalced administered orally should be considered in PD patients and when severe hypercalcemia occurs.

Treatment of secondary hyperparathyroidism with paricalcitol with or without cinacalcet in hemodialysis patients.

INTRODUCTION    Secondary hyperparathyroidism (SHPT) is a common hormonal disorder associated with chronic kidney disease (CKD). The treatment of SHPT should lead to a reduction in parathormone concentrations by calcimimetics or active vitamin D administration and stabilization of calciumand phosphate metabolism. In the event of failure of conservative treatment, complete or partial parathyroid resection should be considered. OBJECTIVES    The aim of the study was to assess the beneficial effects of a combination treatment with paricalcitol and cinacalcet in comparison with paricalcitol alone. PATIENTS AND METHODS    A total of 64 hemodialyzed patients (mean [SD] age, 58 [16] years) with inadequate control of serum parathyroid hormone levels were treated with intravenous paricalcitol, while 16 patients simultaneously received oral cinacalcet. Laboratory tests (intact parathormone [iPTH], calcium, phosphorus) were performed on a monthly basis. In the study, iPTH, calium, phosphorus, and alkaline phosphatase levels were assessed at baseline and after 24 weeks of treatment with paricalcitol alone or in combination with cinacalcet. RESULTS    In both groups, a significant decrease in the iPTH level was observed. Although paricalcitol affects calcium levels, no hypercalcemia was observed. The combination treatment did not result in a significant lowering of iPTH levels in comparison with paricalcitol alone. CONCLUSIONS    Treatment of SHPT with intravenous paricalcitol in patients on hemodialysis is effective and has a good safety profile. The combination of paricalcitol and cinacalcet does not improve the outcomes. Moreover, the combined treatment does not affect calcium and phosphorus concentrations. The cost­effectiveness of therapy should also be considered.

[Treatment of secondary hyperparathyroidism in hemodialysed patients--paricalcitol with or without cinacalcet]. / Leczenie wtórnej nadczynnosci przytarczyc u chorych hemodializowanych--parykalcytol razem z cynakalcetem czy osobno?

Secondary hyperparathyroidism (sHPT) is a common complication being a consequence of metabolic disorders associated with chronic kidney disease (CKD). Treatment of the sHPT should lead to calcium-phosphate management stabilization and parathyroid hormone levels reduction. The phosphate binders, synthetic vitamin D analogs and calcimimetics are used in sHPT treatment. In this paper we analyzed the results of three month paricalcitol treatment of 36 hemodialysis patients with sHPT (serum iPTH> 500 pg/ml). 11 patients have additionally received cinacalcet. Analysis of the results showes a statistically significant reduction in iPTH and alkaline phosphatase. Paricalcitol is effecitve in the tratment of SHPT with favourable profile of side effects. Alcaline phosphatase reduction may be a desirable additional therapeuctic effect. However, it appears that combined therapy with paricalcitol and cinacalcet shoud be offered to selected population of patients i.e. with hypocalcemia after calcimimetics.

[Contemporary opinions on the diagnosis and treatment of secondary hyperparathyroidism].

Secondary hyperparathyroidism is one of the most common hormonal disorders associated with a chronic kidney disease. The main causes of this disease are associated with renal failure hyperphosphatemia, hypocalcemia, and active form of vitamin D deficiency. The progressive secondary hyperparathyroidism leads to a series of complications known as a mineral and bone disorder in a chronic kidney disease. In the treatment of secondary hyperparathyroidism the most important role is played by stabilization of calcium-phosphate metabolism (through proper diet regimen, the use of phosphate binders) and reducing the synthesis and secretion of parathyroid hormone by the administration of calcimimetics and preparations of vitamin D. In the event of failure of conservative treatment complete or partial parathyroid resection should be considered.