Is It Worth Correcting Hyperparathyroidism if Hyperphosphatemia and Hypocalcemia Worsen? A Cinacalcet Story
Kamyar Kalantar-Zadeh, Csaba P. Kovesdy
American Journal of Kidney Diseases
February 2009 (Vol. 53, Issue 2, Pages 183-188) Full Text |
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Dietary Protein Restriction in CKD: The Debate Continues
T. Alp Ikizler
American Journal of Kidney Diseases
February 2009 (Vol. 53, Issue 2, Pages 189-191) Full Text |
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Is Angiotensin-Converting Enzyme Inhibitor and Angiotensin Receptor Blocker Combination Therapy Better Than Monotherapy and Safe in Patients With CKD?
Jeffrey S. Berns
American Journal of Kidney Diseases
February 2009 (Vol. 53, Issue 2, Pages 192-196) Full Text |
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Associations of Dialysis Modality and Infectious Mortality in Incident Dialysis Patients in Australia and New Zealand
, 22 September 2008
David W. Johnson, Hannah Dent, Carmel M. Hawley, Stephen P. McDonald, Johan B. Rosman, Fiona G. Brown, Kym M. Bannister, Kathryn J. Wiggins
American Journal of Kidney Diseases
February 2009 (Vol. 53, Issue 2, Pages 290-297) Abstract |
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See Chonchol et al, pages 197-207; and Kalantar-Zadeh and Kovesdy, pages 183-188.
Patients with CKD often have secondary hyperparathyroidism. In this issue, Chonchol et al conducted a phase 3 study to investigate the safety and efficacy of cinacalcet for secondary hyperparathyroidism in individuals with stage 3 to 4 CKD. In the study, 404 participants from 73 centers in 9 countries were given either cinacalcet or a placebo (3:1 ratio). A greater proportion of cinacalcet than placebo participants achieved a 30% or greater decrease in iPTH level (74% versus 28%; P < 0.001), corresponding to a 43.1% decrease in iPTH level from baseline (cinacalcet) compared with a 1.1% increase (placebo). However, more patients in the cincalcet group had elevated serum phosphorus or low serum calcium than in the placebo group. An editorial by Kalantar-Zadeh and Kovesdy opines that although the study results may seem promising, given the accompanying effects on phosphorus and calcium levels, the use of cinacalcet as an adjunct therapy needs further investigation.
The Effect of Very-Low-Protein Diets on CKD Progression
See Menon et al, pages 208-217; and Ikizler, pages 189-191.
The safety and efficacy of very-low-protein diets supplemented with keto and amino acid mixtures (VLPD-KA) on the progression of kidney disease is much debated. In this issue, Menon et al analyzed the effect of a VLPD on the development of kidney failure and death during long-term follow-up of Study B of the Modification of Diet in Renal Disease (MDRD) Study. MDRD Study B was a randomized controlled trial, including 255 participants with predominantly stage 4 nondiabetic CKD who were assigned to treatment with a LPD or a VLPD-KA. The trial was conducted from 1989 to 1993, and follow up was until 2000. During the trial, there was no significant benefit or risk of the VLPD-KA compared to the LPD. After the trial, there was no specific dietary intervention or clinical monitoring. During long-term follow-up, 89% of the Study B participants developed kidney failure, and there was no benefit of the VLPD-KA on delaying the development of kidney failure. However, there was an increased the risk of death in the VLPD-KA group, which was most significant after initiation of long-term dialysis. Menon et al speculate on potential causes for the increase mortality risk in patients in the VLPD-KA group. An editorial by Dr. Ikizler commends Menon et al on their attempt to explore the important question of VLPD-KA intervention and its effect on nutritional status despite the limitations of their study.
See Arıcı and Erdem, pages 332-345; and Berns, pages 192-196.
Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) have numerous beneficial effects in cardiovascular and kidney disease. Recently, there has been enthusiasm for dual blockade of the renin-angiotensin system, especially to lower proteinuria in patients with kidney disease. In this issue, 2 articles examine the use of dual therapy in clinical practice. A narrative review by Arıcı and Erdem examines this approach in hypertension, cardiovascular disease, and chronic kidney disease. An “In the Literature” editorial by Dr Berns examines the recently published results (in the New England Journal of Medicine and the Lancet) from ONTARGET, a randomized controlled trial of dual versus single therapy in patients with high-risk hypertension and low levels of proteinuria. In contrast to studies of ACE inhibitors and ARBs in patients with kidney disease and high levels of proteinuria, dual therapy did not improve cardiovascular disease and increased the risk of progression of kidney disease, despite greater reduction in proteinuria. Dr Berns questions whether reduction in proteinuria is a reliable surrogate of clinical outcomes and urges further study using clinical outcomes in kidney disease.
Dialysis Modality and Infectious Mortality in Australia and New Zealand
See Johnson et al, pages 290-297.
Infection is a major cause of morbidity and the second leading cause of death in dialysis populations. In this issue, Johnson et al compare rates, types, causes, and timing of infectious death in incident peritoneal dialysis (PD) and hemodialysis (HD) patients in Australia and New Zealand. Using data from the Australian and New Zealand Dialysis and Transplant Registry, they examined 21,935 patients starting dialysis therapy between April 1, 1995, and December 31, 2005 (PD, n = 6,020; HD, n = 15,915). 1,163 patients (5.1%) died of infectious causes (529 PD patients [7.6%] versus 634 HD patients [4.2%]). Incidence rates of infectious mortality in PD and HD patients were 2.8 and 1.7/100 patient-years, respectively. After statistical adjustment, PD was associated with increased hazard of death from infection compared with HD after 6 months of treatment, largely due to bacterial or fungal peritonitis.
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