Toussaint Nigel D, Damasiewicz Matthew J
Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia.
Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia.
Nephrology (Carlton). 2017 Mar;22 Suppl 2:51-56. doi: 10.1111/nep.13026.
The primary indication for administration of calcitriol or other vitamin D receptor activators (VDRA) in chronic kidney disease (CKD) is secondary hyperparathyroidism (SHPT). Prevention and treatment of SHPT appears important, as imbalances in mineral metabolism are associated with renal osteodystrophy, and higher parathyroid hormone (PTH) levels are associated with increased rates of mortality and morbidity in CKD patients. There is, however, a lack of controlled trial data that show lowering PTH with calcitriol/VDRA equates to improved clinical outcomes. Recent randomized controlled trials have concentrated on potential benefits of calcitriol/VDRA on cardiovascular outcomes and reduction of proteinuria and on possible differences between calcitriol and the various VDRA. Several systematic reviews and meta-analyses have also been published, evaluating the benefits and harms of calcitriol/VDRA. Concerns have been raised about the effectiveness of calcitriol/VDRA for suppression of SHPT in the CKD stages 3-5 population, as well as potential adverse outcomes such as hypercalcaemia and elevation in FGF23 levels, suggesting their routine use to treat SHPT in the pre-dialysis CKD population may not be favourable. Conversely, concerns still exist about the wide PTH range in advanced CKD, and that high values may negatively impact bone quality, result in the progression of parathyroid hyperplasia and decrease the effectiveness of treatments to reduce PTH. We discuss the current controversies relating to the challenges in the management of SHPT in patients with CKD stages 3-5 and the need for more evidence to determine the efficacy or harm of using calcitriol/VDRA in this population.
在慢性肾脏病（CKD）中，使用骨化三醇或其他维生素D受体激活剂（VDRA）的主要指征是继发性甲状旁腺功能亢进（SHPT）。预防和治疗SHPT显得很重要，因为矿物质代谢失衡与肾性骨营养不良相关，而较高的甲状旁腺激素（PTH）水平与CKD患者的死亡率和发病率增加有关。然而，缺乏对照试验数据表明使用骨化三醇/VDRA降低PTH等同于改善临床结局。最近的随机对照试验集中在骨化三醇/VDRA对心血管结局和蛋白尿减少的潜在益处，以及骨化三醇与各种VDRA之间可能存在的差异。也发表了几项系统评价和荟萃分析，评估骨化三醇/VDRA的益处和危害。有人对骨化三醇/VDRA在CKD 3-5期人群中抑制SHPT的有效性，以及高钙血症和FGF23水平升高之类的潜在不良结局表示担忧，这表明在透析前CKD人群中常规使用它们来治疗SHPT可能并不合适。相反，对于晚期CKD中PTH范围较宽以及高值可能对骨质量产生负面影响、导致甲状旁腺增生进展并降低降低PTH治疗的有效性，人们仍然存在担忧。我们讨论了与CKD 3-5期患者SHPT管理挑战相关的当前争议，以及需要更多证据来确定在该人群中使用骨化三醇/VDRA的疗效或危害。
