[A long-term comparative study of calcitriol versus alphacalcidol in patients with secondary hyperparathyroidism on hemodialysis]. / Estudio comparativo a largo plazo entre calcitriol y alfacalcidol en pacientes con hiperparatiroidismo secundario en hemodiálisis.

UNLABELLED: Calcitriol has traditionally been the most widely used treatment for secondary hyperparathyroidism (SHPT) in uremic patients. There are currently no crossover equivalence studies of alphacalcidol versus calcitriol establishing which of the two derivatives is more active and better tolerated. The objective of this study was to compare the long term effect on control of PTH of similar doses of alphacalcidol versus calcitriol in the treatment of SHPT in these patients. METHODS: We conducted a retrospective study on 21 hemodialysis patients with stable SHPT of varying severity treated with intravenous calcitriol. In July 2002, the pharmacy of the reference hospital decided to substitute calcitriol for alphacalcidol based on the similarity of the two drugs. The conversion was made substituting a similar amount of drug. Mean absolute serum levels and percentage change in PTH, calcium and phosphorus were compared between the two periods and at 0, 3, 6, 9, 12 and 15 months after starting treatment with alphacalcidol. Student's t-test for paired means was used to compare the values between the two periods. RESULTS: In the calcitriol period, mean PTH levels were 275.2 +/- 111.7 pg/ml. The mean dose of drug used was 1.7 +/- 0.8 mcg postdialysis, and serum calcium and phosphorus levels were 10.1 +/- 0,5 mg/dl and 5,2 +/- 0,9 mg/dl, respectively (p < 0.01). Mean dialysate calcium content was 2,9 +/- 0,3 mEq/l. In the alphacalcidol period, PTH increased (441.6 +/- 178.3 pg/ml) (p < 0.001) and the percentage of patients with PTH < 300 pg/ml decreased (24% at the end of the period), in spite of significantly increasing the mean drug dose (2,3 +/- 0,9 mcg postdialysis) (p < 0.05). Serum calcium levels did not show significant differences (10.2 +/- 0.7 mg/dl) (p = NS), but phosphorus control was improved (4,7 +/- 0,5 mg/dl) (p < 0.01). The percentage of patients with PTH < 300 pg/ml decreased progressively from the start of treatment with alphacalcidol from 75% to 24% at the end of follow-up. Our results seem to suggest that the dose of alphacalcidol and calcitriol are not equivalent and we need to increase the dose of alphacalcidol to obtain a similar result to calcitriol on suppression of PTH in uremic patients with SPTH.

[Hypokaliemic nephropathy as a form of presentation of Conn syndrome]. / Nefropatía hipokaliémica como presentación de un síndrome de Conn.

Hypokalemia is generally associated to neuromuscular symtoms, acid-base disorders and even to rhabdomyolysis. However, chronic hypokalemia can induce chronic renal failure through a characteristic tubulointerstitial damage consisting on vacuolization of epithelial tubular cells and interstitial fibrosis. This entity is called hypokalemic nephropathy, quite unusual and probably little know in our speciality. We present a clinical report of a patient admitted to our hospital with a severe hypokalemia secondary to an aldosterone producing adrenal adenoma that was diagnosed during admission. Besides hypokalemia the patient presented renal failure. Renal biopsy proved characteristic tubulointerstitial damage as described in hypokaliemic nephropathy. In summary, we report a Conn syndrome presenting as a hypokalemic nephropathy.

Estudio comparativo a largo plazo entre calcitriol y alfacalcidol en pacientes con hiperparatiroidismo secundario en hemodiálisis / A long-term comparative study of calcitriol versus alphacalcidol in patients with secondary hyperparathyroidism on hemodialysis

En la actualidad existen diversos derivados de la vitamina D para tratar el hiperparatiroidismosecundario (HPTS) en la uremia. No existen estudios de equivalenciacruzados entre alfacalcidol y calcitriol que permitan establecer cual delos dos derivados es el más activo y el mejor tolerado. El objetivo de este estudiofue comparar el efecto del alfacalcidol y el calcitriol a dosis similares en eltratamiento del HPTS a largo plazo.Métodos: Se estudiaron retrospectivamente 21 pacientes en HD con HPTS establede diferente severidad en tratamiento con calcitriol intravenoso. En julio de2002, por decisión de la farmacia del hospital de referencia y en base a la similitudentre ambos fármacos, se realizó el cambio de producto sustituyendose elcalcitriol por alfacalcidol. Para el tratamiento de los pacientes la conversión se realizósustituyendo un fármaco por otro a la misma dosis. Se comparó la media delos niveles séricos absolutos y el porcentaje de cambio de PTH, calcio y fósforoentre ambos periodos y a los 0, 3, 6, 9, 12 y 15 meses de iniciado el tratamientocon alfacalcidol. Para comparar las medias de los valores analizados entre losdos periodos se realizó un estudio de medias apareadas (test t-student).Resultados: En la etapa de calcitriol, la media de los niveles de PTH fue 275,2± 111,7 pg/ml. La dosis media de calcitriol utilizada fue 1,7 ± 0,8 microgramospostdiálisis, los niveles séricos de calcio fueron 10,1 ± 0,5 mg/dl y el fósforo 5,2± 0,9 p < 0,01 mg/dl. El calcio del dializado fue 2,9 ± 0,3 mEq/l. En la etapa dealfacalcidol la PTH aumentó (441,6 ± 178,3 pg/ml) (p < 0,001), y se redujo elporcentaje de pacientes con PTH < 300 pg/ml (24% al final del periodo) a pesarde haber aumentado de forma significativa la dosis media de alfacalcidol (2,3 ±0,9 microgramos postdiálisis) (p < 0,05). Los niveles séricos de calcio no mostrarondiferencias significativas (10,2 ± 0,7 mg/dl) (p = NS) y el fósforo mostró unmejor control (4,7 ± 0,5 mg/dl) (p < 0,01). El porcentaje de pacientes con PTH< 300 pg/ml fue descendiendo progresivamente en la etapa alfacalcidol, desde75% hasta 24% al final del seguimiento. Nuestros resultados sugieren que lasdosis del alfacalcidol y calcitriol no son equivalentes y que son necesarias mayoresdosis de alfacalcidol para obtener niveles similares de supresión de PTH enpacientes urémicos con HPTS

Calcitriol has traditionally been the most widely used treatment for secondaryhyperparathyroidism (SHPT) in uremic patients. There are currently no crossoverequivalence studies of alphacalcidol versus calcitriol establishing which of the twoderivatives is more active and better tolerated. The objective of this study was tocompare the long term effect on control of PTH of similar doses of alphacalcidolversus calcitriol in the treatment of SHPT in these patients.Methods: We conducted a retrospective study on 21 hemodialysis patients withstable SHPT of varying severity treated with intravenous calcitriol. In july 2002,the pharmacy of the reference hospital decided to substitute calcitriol for alphacalcidolbased on the similarity of the two drugs. The conversion was made substitutinga similar amount of drug. Mean absolute serum levels and percentage changein PTH, calcium and phosphorus were compared between the two periods andat 0, 3, 6, 9, 12 and 15 months after starting treatment with alphacalcidol. Student’st-test for paired means was used to compare the values between the twoperiods.Results: In the calcitriol period, mean PTH levels were 275.2 ± 111.7 pg/ml. Themean dose of drug used was 1.7 ± 0.8 mcg postdialysis, and serum calcium andphosphorus levels were 10.1 ± 0,5 mg/dl and 5,2 ± 0,9 mg/dl, respectively (p <0.01). Mean dialysate calcium content was 2,9 ± 0,3 mEq/l. In the alphacalcidolperiod, PTH increased (441.6 ± 178.3 pg/ml) (p < 0.001) and the percentage ofpatients with PTH < 300 pg/ml decreased (24% at the end of the period), in spiteof significantly increasing the mean drug dose (2,3 ± 0,9 mcg postdialysis) (p <0.05). Serum calcium levels did not show significant differences (10.2 ± 0.7 mg/dl)(p = NS), but phosphorus control was improved (4,7 ± 0,5 mg/dl) (p < 0.01). Thepercentage of patients with PTH < 300 pg/ml decreased progressively from thestart of treatment with alphacalcidol from 75% to 24% at the end of follow-up.Our results seem to suggest that the dose of alphacalcidol and calcitriol are notequivalent and we need to increase the dose of alphacalcidol to obtain a similarresult to calcitriol on suppression of PTH in uremic patients with SPTH

Estudio comparativo a largo plazo entre calcitriol y alfacalcidol en pacientes con hiperparatiroidismo secundario en hemodiálisis / Long-term comparative study between calcitriol and alfacalcidol in patients

En la actualidad existen diversos derivados de la vitamina D para tratar el hiperparatiroidismo secundario (HPTS) en la uremia. No existen estudios de equivalencia cruzados entre alfacalcidol y calcitriol que permitan establecer cual de los dos derivados es el más activo y el mejor tolerado. El objetivo de este estudio fue comparar el efecto del alfacalcidol y el calcitriol a dosis similares en el tratamiento del HPTS a largo plazo. Métodos: Se estudiaron retrospectivamente 21 pacientes en HD con HPTS estable de diferente severidad en tratamiento con calcitriol intravenoso. En julio de 2002, por decisión de la farmacia del hospital de referencia y en base a la similitud entre ambos fármacos, se realizó el cambio de producto sustituyendose el calcitriol por alfacalcidol. Para el tratamiento de los pacientes la conversión se realizó sustituyendo un fármaco por otro a la misma dosis. Se comparó la media de los niveles séricos absolutos y el porcentaje de cambio de PTH, calcio y fósforo entre ambos periodos y a los 0, 3, 6, 9, 12 y 15 meses de iniciado el tratamiento con alfacalcidol. Para comparar las medias de los valores analizados entre los dos periodos se realizó un estudio de medias apareadas (test t-student). Resultados: En la etapa de calcitriol, la media de los niveles de PTH fue 275,2 ± 111,7 pg/ml. La dosis media de calcitriol utilizada fue 1,7 ± 0,8 microgramos postdiálisis, los niveles séricos de calcio fueron 10,1 ± 0,5 mg/dl y el fósforo 5,2 ± 0,9 p < 0,01 mg/dl. El calcio del dializado fue 2,9 ± 0,3 mEq/l. En la etapa de alfacalcidol la PTH aumentó (441,6 ± 178,3 pg/ml) (p < 0,001), y se redujo el porcentaje de pacientes con PTH < 300 pg/ml (24% al final del periodo) a pesar de haber aumentado de forma significativa la dosis media de alfacalcidol (2,3 ± 0,9 microgramos postdiálisis) (p < 0,05). Los niveles séricos de calcio no mostraron diferencias significativas (10,2 ± 0,7 mg/dl) (p = NS) y el fósforo mostró un mejor control (4,7 ± 0,5 mg/dl) (p < 0,01). El porcentaje de pacientes con PTH < 300 pg/ml fue descendiendo progresivamente en la etapa alfacalcidol, desde 75% hasta 24% al final del seguimiento. Nuestros resultados sugieren que las dosis del alfacalcidol y calcitriol no son equivalentes y que son necesarias mayores dosis de alfacalcidol para obtener niveles similares de supresión de PTH en pacientes urémicos con HPTS

Calcitriol has traditionally been the most widely used treatment for secondary hyperparathyroidism (SHPT) in uremic patients. There are currently no crossover equivalence studies of alphacalcidol versus calcitriol establishing which of the two derivatives is more active and better tolerated. The objective of this study was to compare the long term effect on control of PTH of similar doses of alphacalcidol versus calcitriol in the treatment of SHPT in these patients. Methods: We conducted a retrospective study on 21 hemodialysis patients with stable SHPT of varying severity treated with intravenous calcitriol. In july 2002, the pharmacy of the reference hospital decided to substitute calcitriol for alphacalcidol based on the similarity of the two drugs. The conversion was made substituting a similar amount of drug. Mean absolute serum levels and percentage change in PTH, calcium and phosphorus were compared between the two periods and at 0, 3, 6, 9, 12 and 15 months after starting treatment with alphacalcidol. Student’s t-test for paired means was used to compare the values between the two periods. Results: In the calcitriol period, mean PTH levels were 275.2 ± 111.7 pg/ml. The mean dose of drug used was 1.7 ± 0.8 mcg postdialysis, and serum calcium and phosphorus levels were 10.1 ± 0,5 mg/dl and 5,2 ± 0,9 mg/dl, respectively (p < 0.01). Mean dialysate calcium content was 2,9 ± 0,3 mEq/l. In the alphacalcidol period, PTH increased (441.6 ± 178.3 pg/ml) (p < 0.001) and the percentage of patients with PTH < 300 pg/ml decreased (24% at the end of the period), in spite of significantly increasing the mean drug dose (2,3 ± 0,9 mcg postdialysis) (p < 0.05). Serum calcium levels did not show significant differences (10.2 ± 0.7 mg/dl) (p = NS), but phosphorus control was improved (4,7 ± 0,5 mg/dl) (p < 0.01). The percentage of patients with PTH < 300 pg/ml decreased progressively from the start of treatment with alphacalcidol from 75% to 24% at the end of follow-up. Our results seem to suggest that the dose of alphacalcidol and calcitriol are not equivalent and we need to increase the dose of alphacalcidol to obtain a similar result to calcitriol on suppression of PTH in uremic patients with SPTH

Nefropatía hipokaliémica como presentación de un síndrome de Conn / Hypokaliemic nephropathy as a form of presentation of a Conn syndrome

Una hipopotasemia puede causar alteraciones a nivel neuromuscular, en el equilibrio ácido-base o incluso producir rabdomiólisis. Pero si se trata de una hipopotasemia crónica también puede ser causa de una insuficiencia renal cuyo sustrato histológico reside en una característica lesión túbulo-intersticial consistente en vacuolización de los túbulos renales y fibrosis intersticial. Es la entidad denominada nefropatía hipokaliémica, realmente poco descrita en nuestra especialidad. Presentamos el caso clínico de un paciente que ingresó con una hipopotasemia severa, secundaria a un hiperaldosteronismo primario producido por un adenoma suprarrenal que se diagnosticó durante ese mismo ingreso. Este paciente presentaba además una insuficiencia renal crónica en cuya biopsia renal aparecían las típicas lesiones histológicas a nivel túbulo-intersticial arriba descritas. Se trataba por tanto de un síndrome de Conn que debutaba como una nefropatía hipokaliémica

Hypokalemia is generally associated to neuromuscular symtoms, acid-base disorders and even to rhabdomyolysis. However, chronic hypokalemia can induce chronic renal failure through a characteristic tubulointerstitial damage consisting on vacuolization of epithelial tubular cells and interstitial fibrosis. This entity is called hypokalemic nephropathy, quite unusual and probably little know in our speciality. We present a clinical report of a patient admitted to our hospital with a severe hypokalemia secondary to an aldosterone producing adrenal adenoma that was diagnosed during admission. Besides hypokalemia the patient presented renal failure. Renal biopsy proved characteristic tubulointerstitial damage as described in hypokaliemic nephropathy. In summary, we report a Conn syndrome presenting as a hypokalemic nephropathy

[Impact of a quality program in hemodialysis]. / Impacto del seguimiento de indicadores de calidad en hemodiálisis.

UNLABELLED: One of the requirements of a health care quality management system is to be able to established clinical performance measures (CPM) for its key organisation processes. We described some of the performance measurement that has been used in our hemodialysis unit, since the implementation in the year 2001, of a Quality Management System (QMS). We analyze and compare the effect that the introduction of a ISO 9002 based QMS had in our CPM during the period 2001-2002 (post QMS) vs. the two previous years -1999-2000- (pre QMS). METHODS: We defined several CPM for assessment of hemodialysis adequacy and medical management that covered : Anemia, iron status renal osteodystrophy, hemodialysis prescription and nutritional status , follow up of the established guidelines for vascular access care and prevention of nosocomial infections water quality and general performance outcome like annual crude mortality rate and hospitalization (express as hospital days/patient year). RESULTS: No significant difference was found between both periods regarding annual crude mortality( pre QMS 8.37% vs post QMS 8.95%) or the hospitalization rate ( pre 0.47 patient-days vs. post 0.52 patient-days) . There was a significant difference after implementation of the quality system in the average hemoglobin levels (pre 11.3 +/- 1.5 vs. post 11.9+ +/- .5 p <0,001). Ferritin levels (pre 220 +/- 162 vs. post 313 +/- 373 p<0.01), albumin levels (pre 3.61 +/- 0.46 vs. post 3.82 +/- 0.56 p<0.001) and KTV>1.2 (pre 1.41 +/- 0.26 vs. post 1.50 +/- 0.33 p<0.001). The transferring saturation index (TSI) was unchanged (pre 27.98 +/- 14.39 vs.. post 29.4 +/- 16.66 p=0.11). There was a significant decrease in the average PTH levels (pre 234.9 +/- 285 vs. post 174 +/- 174 p< 0.0001) PTH>300 pg/ml (pre 23.7% vs. post 16.4% p<0.001) calcium levels (pre 10.02 +/- 0.99 vs. 9.83 +/- 0.88 p<0.001), phosphorus (pre 5.50 +/- 1.55 vs. post 5.01 +/- 1.47 p<0.001) as well as serum calcium levels >11 mg/dl (pre 14.6% vs. post 11% p<0.001) and phosphorus >6 g/dl (pre 34% post 21.5% p<0.001). Although the average serum potassium levels decrease (pre 5.51 +/- 0.85 vs. post 5.40 +/- 0.87), the percentage of patients with potassium over 6.5 meq/l was similar in both periods (pre 11.5% vs. post 10. 1%). The number of native A-V vascular access was similar in both periods and above the current DOQI Recommendations. Nevertheless, there was a gradual decrease in native A-V fistula, associated with an increase on the use of permanent catheters. The number of incident patients with a permanent catheter as the only vascular access for hemodialysis increased from 0% in the year 1999, 2000 and 2001 to 6.98% in 2002. There was no hepatitis B and C seroconversión detected in both periods. CONCLUSION: From our study we concluded that regular follow-up of quality performance measurement associated with an ongoing corrective action, promotes an improvement of the outcome measures results.

[Evaluation of health-related quality of life (HRQL) based on information from Coop/Wonca sheets in hemodialysis patients]. / Evaluación de la calidad de vida relacionada con la salud mediante las láminas Coop-Wonca en una población de hemodiálisis.

UNLABELLED: There has been increasing interest to find instruments to assess the HRQL quickly and easily in daily clinical practice. The main objective of this study is to measure the HRQL inhemodialysis patients using the Coop-Wonca Charts and to analyse whether they can be a useful instrument to assess the patient functional status and the HRQL in this population. METHODS: A descriptive cross-sectional study was performed between March 2003 and May 2003 in 163 hemodialysis patients (106 males and 57 females). The HRQL has been measured according to the validated Spanish version of the Coop-Wonca Charts. The questionnaire has nine different scales with a single-item. The answers score from 1 to 5 with the higher scores indicating the worst health or functional problems. RESULTS: The filling middle time of Coop-Wonca charts was less than five minutes. The charts were easily understood for the patients and can be self-administered. The dimensions of "Physical fitness" (3.66 +/- 0.8) and "Overall health" (3.43 +/- 0.8) showed the higher score, and the item aSocial activities) showed the lower scores (better quality of life) (1.98 +/- 1.3). The factors related to the worse health state are the variables: sex (females), the comorbility (diabetes and/or hepatopathy), the labour status (retired) and the way of transport (taxi/ambu lance). The time in hemodialysis was an independent variable and showed the worse score in the "general quality of life" (p < 0.05) and in the "perception of pain" (p < 0.01). The way of transport used (ambulances) was also an independent variable with worse scores for the dimensions "Physical fitness" (p < 0.01), "Daily activities" (p < 0.05) and "Health status" (p < 0.05). The older patients showed a worse score in the dimension "Physical fitness" (p < 0.01) and the patients with more than prescribed medicines scored worse in "Social activities" (p < 0.01). Males (p < 0.05), widows and single (p < 0.05) scored worse in social support. CONCLUSIONS: The Coop-Wonca Charts could be a good instrument to measure of HRQL in the HD patients. Their application is easy, fast (less than 5 minutes), easily understood, and can be self-administered.

[Prognostic significance of programmed dialysis in patients who initiate renal substitutive treatment. Multicenter study in Spain]. / Significado pronóstico de la diálisis programada en pacientes que inician tratamiento sustitutivo renal. Un estudio multicéntrico español.

BACKGROUND: The aim of our study was to analyse patient characteristics, mortality and costs, all of them in relation to whether starting dialysis was planned or unplanned. METHODS: A total of 362 patients (227 male and 135 female) from five hospitals of the National Health System, who were started on chronic renal replacement therapy (RRT) during 1996 and 1997 were included. Patients who were started on RRT after acute renal failure were excluded. We carried out a retrospective analysis of the demographic characteristics, patients' conditions at the time of initiating dialysis and outcome and costs at six and thirty-six months of treatment. Patients were classified as planned (PL-D) or unplanned dialysis (UNPL-D), depending on whether or not the patient had a vascular or peritoneal access ready to use for initiating RRT. RESULTS: One hundred and eighty-six patients (51.4%) started on dialysis in the PL-D group whereas 176 (48.6%) did it as UNPL-D. In this latter group, 135 (37.3% of the total) had previously been monitored by a nephrologist, and 41 (11.3%) initiated dialysis without previous nephrological follow-up. UNPL-D was associated with older age (p < 0.001), non-nephrological follow-up (p < 0.001), diabetes (34.7% vs 22.6%) (p = 0.011), haemodialysis as a first mode of RRT (94.9 vs 81.7%) (p < 0.001), higher comorbidity risk (p < 0.001), dialysis initiation with uraemic symptoms or fluid overload (p < 0.001), increased blood transfusion requirement (p < 0.001) and lower serum albumin (p < 0.001), creatinine clearance (p < 0.001), haemoglobin concentration (p < 0.001), and weight (p = 0.002). In the PL-D group the main primary renal diseases were glomerular and polycystic disease, whereas interstitial and diabetic nephropathy were higher in UNPL-D group (p = 0.005). Multivariate analysis showed that previous non nephrological follow-up, uraemic symptoms, interstitial nephritis as primary renal disease correlated with UNPL-D initiation, and it was followed by choosing haemodialysis as first RRT. UNPL-D was also associated with increased number of days of hospitalization at the initiation of dialysis, and during the first 6 months (p < 0.001), increase of hospitalization days (p = 0.009), and increased 6-month-mortality (10.2% vs 3.2%) (p = 0.015, log rank test), and three-year mortality (24.2 vs 36.9%) (p = 0.006, log rank test). The costs of UNPL-D were fivefold that of the PL-D group. CONCLUSION: UNPL-D has been associated with worse overall clinical conditions at the initiation of chronic replacement therapy, choosing haemodialysis as first RRT, increased morbi-mortality and subsequent increase of costs.

Vitamin D receptor genotype influences parathyroid hormone and calcitriol levels in predialysis patients.

BACKGROUND: BsmI vitamin D receptor (VDR) gene polymorphism has been associated with the severity of hyperparathyroidism in patients on hemodialysis. The aim of this study was to analyze the influence of this polymorphism on parathyroid function and serum calcitriol levels in patients with different degrees of chronic renal failure (CRF) before dialysis. METHODS: A total of 248 CRF patients, divided into three groups according to creatinine clearance (CCr; mild CRF group> 60 to 35 to 10 to 2.5 mmol/liter and serum phosphorus levels of> 1.6 mmol/liter or who needed phosphorus binding agents were excluded. The statistical analysis was done with the general factorial analysis of variance entering first PTH and then calcitriol as the dependent variable; the genotype (BB, Bb and bb), sex and CCr group were defined as factors; and covariables included serum calcium, serum phosphorus, 1/creatinine versus time slope, PTH when calcitriol was the dependent variable, and calcitriol when PTH was the dependent variable. RESULTS: When serum PTH levels were entered as the dependent variable, serum calcium, CCr group, and the interaction of genotype with the CCr group were found to be significant factors (P = 0.025, P <0.001 and P = 0.039, respectively). When serum calcitriol levels were entered as the dependent variable, genotype, the interaction of genotype with CCr, the CCr group, and the 1/creatine versus time slope were found to be significant (P = 0.027, P = 0.028, P <0.001 and P = 0.044, respectively). The marginal means of PTH, adjusted with the general factorial analysis of variance across the three groups were: (a) mild CRF group, BB 5.3 pmol/liter (CI 0 to 13.8), Bb 5.5 pmol/liter (CI 2 to 9), bb 5.4 pmol/liter (CI 0.6 to 10.2); (b) moderate CRF group, BB 6.2 pmol/liter (CI 1.5 to 10.9), Bb 7.8 pmol/liter (CI 5.3 to 10.3), bb 7.5 pmol/liter (CI 4.8 to 10.1); (c) severe CRF group, BB 9.3 pmol/liter (CI 4.2 to 14.3), Bb 17.1 pmol/liter (CI 13.9 to 20.2), bb 21.9 pmol/liter (CI 18.7 to 25.2). The marginal means of calcitriol adjusted with the general factorial analysis of variance across the three groups were: (a) mild CRF group, BB 47 pg/ml (CI 37 to 57), Bb 40.9 pg/ml (CI 37 to 44.8), bb 32.6 pg/ml (CI 26.8 to 38. 4); (b) moderate CRF group, BB 24.1 pg/ml (CI 18.3 to 29.8), Bb 26.6 pg/ml (CI 23.5 to 29.7), bb 25.3 pg/ml (CI 22 to 28.6); (c) severe CRF group, BB 27.4 pg/ml (CI 21.3 to 33.5), Bb 19.4 pg/ml (CI 15.5 to 23.2), bb 20.4 pg/ml (CI 16.1 to 24.7). CONCLUSION: The progression of hyperparathyroidism is slower in predialysis patients with BB genotypes than in the other genotypes. Also, calcitriol levels are less reduced in the BB genotype, which may act to lessen the severity of secondary hyperparathyroidism.

Level-dependent inhibitory effect of hyperaluminaemia on parathyroid hormone secretion in patients with end-stage renal failure.

OBJECTIVES: Serum aluminium and parathyroid hormone levels were measured in chronic dialysis patients at discovery of accidental exposure to high dialysate aluminium levels and followed after adequate water purification. PATIENTS AND METHODS: Twenty-nine patients with chronic renal failure on maintenance haemodialysis were accidently exposed to dialysate aluminium levels of 65 micrograms/L (recommended Food and Drug Administration values less than 10 micrograms/L) for 18 months. At discovery, oral aluminium was withdrawn and dialysate aluminium levels were corrected to less than 5 micrograms/L. Serum aluminium, parathyroid hormone, calcium, phosphorus and alkaline phosphatase levels were determined at discovery and two months and one year after the corrective measures. RESULTS: Mean serum aluminium level was 167.6 +/- 15 micrograms/L at discovery and simultaneous serum parathyroid levels were 7.9 +/- 2.2 pmol/L (normal values 1.1 to 4.6 pmol/L). Two months after discontinuation of oral aluminium and correction of dialysate aluminium levels to less than 5 micrograms/L, the patients' mean serum aluminium dropped to 49.6 +/- 4.3 micrograms/L and simultaneous serum parathyroid hormone levels rose to 14.6 +/- 3.2-pmol/L (p < 0.001). Similar levels were maintained at one year. Serum calcium did not change significantly. There was a significant correlation between the drop in serum aluminium and the increase in parathyroid hormone. CONCLUSION: These results confirm animal experiments and show convincingly that aluminium inhibits parathyroid secretion also in humans.