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Cinacalcet should be used to treat secondary hyperparathyroidism in stage 3–4 chronic kidney disease

Nature Clinical Practice Nephrology volume 4, pages 366–367 (2008)Cite this article

Secondary hyperparathyroidism (SHPT) is a serious and progressive disease that begins early in the course of chronic kidney disease (CKD). SHPT is associated with elevated serum parathyroid hormone (PTH) levels; notable elevations can occur as early as stage 2 CKD (creatinine clearance rate 70–80 ml/min/1.73 m2).1 Increased PTH levels are accompanied by decreased levels of vitamin D and by disordered mineral metabolism (usually high blood calcium and phosphorus levels), both of which can, in turn, result in bone disease, vascular calcification, and, ultimately, death.2 Traditional SHPT therapies, particularly vitamin D sterols and calcium-based phosphate binders, fail to help the majority of patients achieve the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) goals for SHPT.3 Retrospective analysis suggests that maintenance of SHPT parameters within these target ranges is associated with decreased mortality.4

The regulation (and dysregulation) of PTH release in CKD is extremely complex. The calcium-sensing receptor (CaSR) maintains exquisite physiologic control of PTH secretion by the parathyroid gland in response to changes in extracellular calcium levels. The allosteric interaction of the calcimimetic cinacalcet with the CaSR increases the sensitivity of the receptor to extracellular calcium,5 which leads to reduced plasma levels of PTH, calcium, and phosphorus in the dialysis population.6 Although the efficacy of cinacalcet is unaffected by the severity of SHPT,6 post hoc analyses of pooled data from the phase III trials of this agent in patients on dialysis demonstrate that the milder the disease at the start of therapy, the greater the likelihood of attaining KDOQI targets.7

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Authors and Affiliations

  1. ALM de Francisco is a Professor in the Graduate School of Medicine at the University of Cantabria and Head of the Dialysis Unit at the Marqués de Valdecilla University Hospital,

    Angel LM de Francisco

  2. C Piñera and R Palomar are Clinical Staff in the Nephrology Department at the Marqués de Valdecilla University Hospital, Santander, Spain.,

    Celestino Piñera & Rosa Palomar

Authors
  1. Angel LM de Francisco
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  2. Celestino Piñera
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  3. Rosa Palomar
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Correspondence to Angel LM de Francisco.

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Competing interests

ALM de Francisco has received consultancy fees from Amgen. The other authors declared no competing interests.

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de Francisco, A., Piñera, C. & Palomar, R. Cinacalcet should be used to treat secondary hyperparathyroidism in stage 3–4 chronic kidney disease. Nat Rev Nephrol 4, 366–367 (2008). https://doi.org/10.1038/ncpneph0832

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