单用Paricalcitol比并用Cinacalcet对血液透析有更好结果

根据篇在国家肾脏基金会(NKF)2008春季临床会议中发表的中心回溯研究结果，接受透析的慢性肾脏病(CKD)病患单以paricalcitol治疗者，可以比同时使用paricalcitol和cinacalcet的病患有比较好的结果
　　
　　主要作者、伊利诺州Abbott Park的Abbott Renal Care商业发展主任Maria Karalis向Medscape Nephrology表示，CKD病患使用活化维他命D是次发性副甲状腺高能症(SHPT)治疗之基石，有关SHPT的治疗决策随着cinacalcet治疗而益发复杂。
　　
　　CKD使用paricalcitol治疗的基本理由是CKD合并维他命D缺乏以及钙浓度增加，会增加副甲状腺素(PTH)值，发生SHPT是致病率和致死率的重要原因；血管钙化可能是因钙(Ca)和磷(P)值增加所致。
　　
　　Paricalcitol可以成功调节CKD病患的PTH值，且维持适当的钙和磷值，此药是可用于治疗SHPT病患的数维他命D受体活化剂之一；拟钙作用剂，如cincalcet，发展用来治疗因为SHPT而造成的钙值升高。
　　
　　UCLA的David Geffen医学院小儿内科副教授、洛杉矶BioMedical研究中心Harbor-UCLA肾脏与高血压部门校外透析推广与流行病学主任Kamyar Kalantar-Zadeh医师并未参与此研究，但是受邀为Medscape Nephrology提供人建议。
　　
　　Kalantar-Zadeh医师表示，历史研究指出，cinacalcet的角色可以是辅助治疗，单用 paricalcitol 即可以达到目标。
　　
　　Karalis 医师等人搜集了2005年7月至2007年7月之间在美国365家医学中心进行血液透析之14,365名病患的资料，其中8,426名病患以paricalcitol 和/或 cinacalcet 治疗且接受PTH、钙或磷等之检验；研究者比较单用paricalcitol治疗(Z)或者paricalcitol 加 cinacalcet治疗(Z+S)之血液透析CKD病患在治疗后达到的完整的PTH(iPTH)、钙和磷的NKF K/DOQI目标。
　　
　　iPTH 的目标范围在100-300 pg/mL，Z组的病患有 38% 达到，Z+S组有 25%达到；Z组的病患在达到钙目标（8.4 to 9.5 mg/dL）和达到磷目标（3.5 to 5.5 mg/dL）的比率也都优于Z+S组，分别是52% vs. 46%以及48% vs. 39%。
　　
　　Karalis 医师表示，单用paricalcitol治疗的病患在所有的KDOQI目标达成率都比使用paricalcitol和cinacalcet者佳；在加入其他制剂之，应根据仿单的规范让paricalcitol的剂量有最适当的确立。
　　
　　根据些发现，研究者建议，在使用cinacalcet治疗SHPT之前，应再度评估维他命D受体活化剂的适当剂量，特别应考量血液透析病患通常有服用多种药物之负担。
　　
　　若论及附加研究，Karalis医师认为经时分析方法可以提供额外的观点；Kalantar-Zadeh 医师建议进行随机临床试验或者前溯观察研究。
　　
　　Kalantar-Zadeh医师结论表示，此研究的强度包括样本数，且包括了研究族群，减少了取样偏差；限制在于它是观察性质，使得它可能因为适应症而在检验上有所困难，换言之，接受cincalcet的病患可能对标准治疗本来就比较有阻抗性。
　　
　　该研究接受Abbott Renal Care赞助，所有的研究作者都是Abbott的员工。
　　
　　国家肾脏基金会 2008春季临床会议 ：摘要 133。2008年4月2-6日。
　　

Hemodialysis Outcomes May Be B

By Laurie Barclay, MD
Medscape Medical News

Patients with chronic kidney disease (CKD) on hemodialysis treated with paricalcitol alone had better outcomes than did those treated with both paricalcitol and cinacalcet, according to the results of a multicenter, retrospective study presented at the National Kidney Foundation (NKF) 2008 Spring Clinical Meetings in Dallas, Texas.

"The use of activated vitamin D has been the cornerstone of secondary hyperparathyroidism (SHPT) therapy in CKD patients, and therapeutic decisions regarding the treatment of SHPT have become increasingly complicated with the advent of cinacalcet therapy," presenter and lead author Maria Karalis, MBA, RD, LDN, director of commercial development at Abbott Renal Care in Abbott Park, Illinois, told Medscape Nephrology.

The rationale for paricalcitol treatment in CKD is that vitamin D deficiency and increased calcium levels associated with CKD tend to increase levels of parathyroid hormone (PTH), with development of SHPT as a significant cause of morbidity and mortality. Vascular calcification may result from elevated calcium (Ca) and phosphorus (P) levels.

Paricalcitol, which successfully regulates PTH levels in CKD patients and maintains appropriate Ca and P levels, is one of several vitamin D receptor activators now available to treat patients with SHPT. Calcimimetic agents, such as cincalcet, have also been developed to treat elevated Ca levels as SHPT progresses.

Kamyar Kalantar-Zadeh, MD, PhD, MPH, FAAP, FACP, FASN, FAHA, an associate professor of medicine and pediatrics, and director of off-campus dialysis expansion and epidemiology in the Harbor-UCLA Division of Nephrology and Hypertension at the Los Angeles BioMedical Research Institute, and UCLA David Geffen School of Medicine, was not involved in this study, but provided independent commentary for Medscape Nephrology.

"This historical study indicates that the role of cinacalcet can be an adjunct treatment and that paricalcitol alone can achieve target levels," Dr. Kalantar-Zadeh said.

Dr. Karalis and colleagues collected data from 14,365 patients on hemodialysis at 365 US centers from July 2005 to July 2007. Of these, 8426 patients were treated with paricalcitol and/or cinacalcet and underwent laboratory testing for PTH, Ca, or P levels. The investigators compared the percentage of CKD patients on hemodialysis who achieved NKF K/DOQI goals for intact PTH (iPTH), Ca, and P after treatment with paricalcitol alone (Z only) or with paricalcitol plus cinacalcet (Z+S).