mario cozzolino, md, phd nuove acquisizioni nella terapia dell’iperparatiroidismo secondario in...
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Mario Cozzolino, MD, PhD
NUOVE ACQUISIZIONI NELLA NUOVE ACQUISIZIONI NELLA TERAPIA TERAPIA
DELL’DELL’IPERPARATIROIDISMO IPERPARATIROIDISMO SECONDARIO SECONDARIO IN DIALISI IN DIALISI
PERITONEALEPERITONEALE
XV CONVEGNO del Gruppo di Studio di Dialisi Peritoneale
Palermo, 19 Marzo 2010
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NUOVE ACQUISIZIONI NELLA NUOVE ACQUISIZIONI NELLA FISIOPATOLOGIA FISIOPATOLOGIA
DELL’DELL’IPERPARATIROIDISMO IPERPARATIROIDISMO SECONDARIOSECONDARIO
FGF-23
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Dobbiamo dosare l’FGF23
nei pazienti con CKD?
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KDIGO Clinical Practice Guideline for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney
Disease-Mineral and Bone Disorder (CKD-MBD)
VOLUME 76 | SUPPLEMENT 113 | AUGUST 2009
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CKD-MBD
P
PTH
Ca
Vit.D
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KDIGO Clinical Practice Guideline for the Diagnosis, KDIGO Clinical Practice Guideline for the Diagnosis, Evaluation, Prevention, andEvaluation, Prevention, and Treatment of Chronic Treatment of Chronic
Kidney Disease-Mineral and Bone Disorder (CKD-MBD).Kidney Disease-Mineral and Bone Disorder (CKD-MBD).Kidney IntKidney Int 76: S1-130, 2009. 76: S1-130, 2009.
Reduce elevated phosphate levels toward the normal rangeReduce elevated phosphate levels toward the normal range Maintain normal calcium levels Maintain normal calcium levels Use a dialysate Use a dialysate ccaalciumlcium concentration between 1.25 and concentration between 1.25 and
1.50 mmol/L (2.5-3.0 mEq/L)1.50 mmol/L (2.5-3.0 mEq/L)
In CKD patients receiving treatments for CKD-MBD or in whom biochemical abnormalities are identified, it is reasonable to increase the frequency of measurements to monitor for trends and treatment efficacy and side-effects
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Lateral abdominal radiograph and echocardiogram to detect presence/absence respectively of vascular and/or valvular calcification.
Patients with VC should be considered at HIGHEST CV RISK. It is reasonable to use this information to guide the management of CKD-MBD.
KDIGO Clinical Practice Guideline for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-
MBD).Kidney Int 76: S1-130, 2009.
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“We suggest” using P-binders in the treatment of hyperphosphatemia. It is reasonable that the CHOICE of P-binder takes into account:
- CKD stage
- Presence of other components of CKD-MBD (Ca, PTH, ALP, Vascular Calcification)
- Concomitant therapies (VDRAs, Cinacalcet)
- Side effect profile
KDIGO Clinical Practice Guideline for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-
MBD).Kidney Int 76: S1-130, 2009.
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In CKD stages 3-5D and hyperphosphatemia:In CKD stages 3-5D and hyperphosphatemia:
Restricting the dose of cRestricting the dose of calciumalcium-based phosphate binders in the -based phosphate binders in the presence of hypercalcemia (1B), arterial calcification (2C), presence of hypercalcemia (1B), arterial calcification (2C), and/or adynamic bone disease (2C), and/or if serum PTH levels and/or adynamic bone disease (2C), and/or if serum PTH levels are persistently low (2C).are persistently low (2C).
Avoiding the long-term use of aluminum-containing phosphate Avoiding the long-term use of aluminum-containing phosphate binders (1C).binders (1C).
Limiting dietary phosphate intake (2D)Limiting dietary phosphate intake (2D)
Increasing dialytic phosphate removal (2C)Increasing dialytic phosphate removal (2C)
Use of P-Binders
KDIGO Clinical Practice Guideline for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD). Kidney Int 76: S1-130, 2009.
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CKD-MBD and PERITONEAL CKD-MBD and PERITONEAL DIALYSISDIALYSIS
Optimizing the Treatment of Hyperphosphatemia
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Sevelamer Hydrochloride in Sevelamer Hydrochloride in Peritoneal Dialysis Patients: Results Peritoneal Dialysis Patients: Results
of a Multicenter Cross-sectional of a Multicenter Cross-sectional StudyStudy
Rosa Ramos, et al. Rosa Ramos, et al.
Peritoneal Dialysis International Peritoneal Dialysis International 2007; 27:697-7012007; 27:697-701
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22% of Sevelamer-treated pts showed a blood22% of Sevelamer-treated pts showed a bloodHCOHCO33
-- levels <22.0 mmol/L levels <22.0 mmol/L
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Structure of Sevelamer HCl and Structure of Sevelamer HCl and Carbonate Carbonate
Structures adapted from Renagel and Renvela Package Inserts.
• Same polymer backbone: Retains similar phosphate-binding capacity
• Salt change: Potentially improves buffering capacity
Sevelamer HCl Sevelamer Carbonate
NH2-nHCI a NH-nHCI
NH2-nHCI NH-nHCI
b cm
OH
NH3+
a
NH
NH2 NH
b cm
OH
HCO3-
a, b = number of primary amine groups a + b = 9c = number of cross-linking groups c = 1n = fraction of protonated amines n = 0.4m = large number to indicate extended polymer network
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Sevelamer Carbonate: Sevelamer Carbonate: Significance of Improving Significance of Improving
Buffering CapacityBuffering Capacity Low bicarbonate levels are common in
CKD patients, regardless of phosphate binder choice
Removal of hydrochloride from Sevelamer HCl and the addition of carbonate from Sevelamer Carbonate to the GI tract may facilitate maintaining bicarbonate levels within recommended guidelines ranges
KDOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease. Available at http://www.kidney.org/professionals/KDOQI/guidelines_bone/Guide15.htm
Duggal A, Hanus M, Zhorov E, et al. J Ren Nutr 2006;16(3):248-252
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3% of Lanthanum-treated pts showed a blood3% of Lanthanum-treated pts showed a bloodHCOHCO33
-- levels <22.0 mmol/L levels <22.0 mmol/L
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CKD-MBD
PTH
PCa
Vit.D
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KDIGO Clinical Practice Guideline for the Diagnosis, KDIGO Clinical Practice Guideline for the Diagnosis, Evaluation, Prevention, andEvaluation, Prevention, and Treatment of Chronic Treatment of Chronic
Kidney Disease-Mineral and Bone Disorder (CKD-MBD).Kidney Disease-Mineral and Bone Disorder (CKD-MBD).Kidney IntKidney Int 76: S1-130, 2009. 76: S1-130, 2009.
–Maintain iPTH levels in the range of approximately 2 to 9 times the upper normal limit for the assay.
Mark changes in iPTH levels in either direction within this range prompt an initiation or change in therapy to avoid progression to levels outside of this range
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Proposed KProposed KDIGODIGO Guidelines: Guidelines: Target Range for PTHTarget Range for PTH
K/DOQIPTH
Target(pg/mL)
100
150 300
500
– Low bone turnover– Adynamic bone disease
– High bone turnover– Bone pain– Cardiovascular disease– Cognitive impairment
KDIGO2-9 times
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“We suggest” using VDRAs and/or cinacalcet in patients with CKD stage 5D and elevated or rising PTH. It is reasonable that INTIAL DRUG SELECTION for the treatment of elevated PTH be based on:
- Serum Ca and P levels
- Other aspects of CKD-MBD (ALP, Vascular Calcification)
- Concomitant therapies (Calcium containing P binders)
- Side effect profile
KDIGO Clinical Practice Guideline for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral
and Bone Disorder (CKD-MBD).Kidney Int 76: S1-130, 2009.
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CKD-MBD and PERITONEAL CKD-MBD and PERITONEAL DIALYSISDIALYSIS
Optimizing the Treatment of SHPT
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Cinacalcet HCl, an Oral Calcimimetic Cinacalcet HCl, an Oral Calcimimetic Agent for the Treatment of SHPT in Agent for the Treatment of SHPT in HD and PD: a Randomized, Double-HD and PD: a Randomized, Double-
Blind, Multicenter StudyBlind, Multicenter Study
Jill Lindberg, et al. Jill Lindberg, et al.
JASN 2005; 16: 800-807JASN 2005; 16: 800-807
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Safety and Efficacy of Pulse and Daily Safety and Efficacy of Pulse and Daily Calcitriol in Patients on CAPD: a Calcitriol in Patients on CAPD: a
Randomized TrialRandomized Trial
Sharon Moe, et al. Sharon Moe, et al.
NDT 1998; 13: 1234-1241NDT 1998; 13: 1234-1241
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Oral Paricalcitol for the Treatment ofOral Paricalcitol for the Treatment ofSecondary Hyperparathyroidism in Secondary Hyperparathyroidism in
Patients on Hemodialysis or Patients on Hemodialysis or Peritoneal DialysisPeritoneal Dialysis
Edward A. Ross, et alEdward A. Ross, et al
Am J Nephrol 2008; 28:97–106Am J Nephrol 2008; 28:97–106
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Effects of oral paricalcitol in reducing PTH Study design
88 CKD Stage 5 pts with SHPT (iPTH ≥300 pg/mL; sCa 8.0–10.5 mg/dL; Ca x P ≤65 mg2/dL2) receiving chronic HD (n=62) or PD (n=26) randomised to oral paricalcitol or placebo for 12 weeks
Primary endpoints:Efficacy: 2 consecutive iPTH decreases ≥30% from
baselineSafety: Development of hypercalcemia (2 consecutive Ca
measurements >11.0 mg/dL)
Secondary endpoints:Absolute and percentage changes in iPTH and markers of
biochemical bone activity (BSAP, osteocalcin, collagen C-telopeptides (CTx), tartrate resistant acid phosphatase isoform 5b (TRAP-5b)
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Decreases in iPTH with Decreases in iPTH with paricalcitolparicalcitol
88
100
83
13
0
16
0
20
40
60
80
100
120
All patients PD HD
Pat
ien
ts (
%)
**
*
*p<0.001
Primary endpoint: % patients with 2 consecutive ≥30% decreases in iPTH from baseline
-27,8
-21
-43,9
20,4 22,4
14,1
-50
-40
-30
-20
-10
0
10
20
30
All patients PD HD
Paricalcitol Placebo
Mea
n %
Δ f
rom
bas
elin
e in
iPT
H
Change from baseline to last on-treatment visit
**
*
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Observed mean values of iPTH, Ca Observed mean values of iPTH, Ca and P during treatment phaseand P during treatment phase
Weeks since first dose of study drug
PlaceboParicalcitol
10
9
8
7
6
5
0 2 4 6 8 10 12
5
4
3
8
7
6
10
9
Phosphorus
Calcium
Me
an
sP
(m
g/d
L)
Me
an
sC
a (
mg
/dL
)
p<0.001 at each timepoint
1000
900
800
700
600
500
0 2 4 6 8 10 12
Me
an
iP
TH
(p
g/m
L)
400
500
11
• Hypercalcemia (≥2 consecutive Ca >11.0 mg/dL): 2% paricalcitol; 0% placebo
• Ca in normal range throughout for both groups
• No statistically significant differences in P
• Ca x P <55 mg2/dL2 throughout
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The Role of Paricalcitol beyond The Role of Paricalcitol beyond PTH Suppression PTH Suppression
Cardio-protectionCardio-protectionRenal protectionRenal protectionReduction of inflammatory markersReduction of inflammatory markersPrevention of vascular calcificationPrevention of vascular calcificationPrevention of oxidative stressPrevention of oxidative stress
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CKD-MBDin PD
SUMMARYSUMMARY
P Binders
Ca Bath
Paricalcitol
Cinacalcet
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THANKS for your ATTENTION!