[New therapy strategies in secondary hyperparathyroidism on dialysis (I): new concepts, new treatments]. / Nuevas estrategias terapéuticas para el hiperparatiroicismo secundario en diálisis (I): nuevos conceptos, nuevos tratamientos.

Secondary hyperparathyroidism (SHP) is still an early and frequent complication of chronic renal disease (CRD). Currently, CRD is an independent cardiovascular risk factor, and calcium-phosphorus metabolism is one of the modifiable related factors. In this first article, we summarize the recent SHP treatment paradigm shift in dialysis patients, derived from the better knowledge and understanding of vascular calcification. We analyze the most recent guidelines (K/DOQI), and describe the general implications of hyperphosphatemia, as well as our therapeutic approach with phosphorus-binders. Since sevelamer additionally presents some pleiotropic effects and it attenuates the progression of vascular calcification, we consider it in the first-line of treatment despite it is not yet demonstrated a survival benefit. We also minimize the use of elemental calcium to a maximum of 1000 to 1500 mg/day. Lanthanum carbonate may well be an important therapeutic agent in the near future, especially if security concerns related to metal accumulation are overcome. Ferric citrate, colestilan and nicotinamide may soon play a role. All these drugs, isolated or in combination, are important in the treatment of SHP since a great deal of its success and the avoidance of some dialysis-related complications depend on an efficient phosphorus control.

[New therapeutic strategies in secondary hyperparathyroidism on dialysis (II): vitamin D analogues and calcium-mimetics]. / Nuevas estrategias terapéuticas para el hiperparatiroidismo secundario en diálisis (11): análogos de la vitamina D y calcimiméticos.

Secondary hyperparathyroidism (SHP) is a frequent complication of dialysis patients. In this second article we will analyze the new vitamin D analogs, capable of decreasing parathyroid hormone (PTH) levels with a lower effect on intestinal calcium and phosphorus absorption. Among other advantages described in the experimental setting, paricalcitol shows a survival benefit in dialysis patients as compared to calcitriol, at least in retrospective studies, and thus it became our first-line vitamin D derivative. Calcimimetics are unique since they decrease PTH levels without increasing serum calcium and phosphorus. Actually, calcium and phosphorus decrease in a significant number of patients. These drugs will soon be authorized in Spain, and we describe the better achievement of K/DOQI guidelines as well as other beneficial effects observed in the experimental animal with them. Finally, we mention the potential benefit of mild metabolic acidosis, the use of bisphosphonates, the role of bone morphogenetic protein BMP-7, and the use of teriparatide. The future treatment of SHP will probably require the independent management of calcium, phosphorus, vitamin D and PTH. Thus, low-dose combined treatments with selective drugs may prove more effective than sequential therapies.

Nuevas estrategias terapéuticas para el hiperparatiroidismo secundario en diálisis (I): nuevos conceptos, nuevos tratamientos / New therapy strategies in secondary hyperparathyroidism on dialysis (I): new concepts. New treatments

El hiperparatiroidismo secundario (HPS) es una complicación frecuente y precozde la enfermedad renal crónica (ERC). La ERC es hoy un factor de riesgo cardiovascularindependiente y las alteraciones del metabolismo calcio-fósforo sonuno de sus factores inherentes modificables. En este primer artículo resumimos loscambios conceptuales recientes en pacientes en diálisis, derivados del reconocimientoy fisiopatología de la calcificación vascular, analizando las guías más actuales(K/DOQI), definiendo las implicaciones generales de la hiperfosfatemia ydescribiendo nuestra actitud terapéutica en relación a los captores del fósforo.Dada la atenuación de la progresión de la calcificación vascular y sus efectospleiotrópicos, consideramos el sevelamer como el captor de elección aunque aúnno haya demostrado una mejoría en la supervivencia, limitando en cualquier casoel uso de captores de calcio a 1.000-1.500 mg/día de calcio elemento. El carbonatode lantano es una importante alternativa terapéutica de futuro, especialmentesi se aclaran los problemas de seguridad relacionados con la potencial acumulacióndel metal. Las sales de hierro y los más recientes colestilán y nicotinamidapueden también jugar próximamente un papel. Del eficiente control del fósforo,con una sola droga o varias en combinación, depende hoy no sólo el éxito deltratamiento del HPS sino también el control de complicaciones graves asociadasa la diálisis

Secondary hyperparathyroidism (SHP) is still an early and frequent complicationof chronic renal disease (CRD). Currently, CRD is an independent cardiovascularrisk factor, and calcium-phosphorus metabolism is one of the modifiable relatedfactors. In this first article, we summarize the recent SHP treatment paradigmshift in dialysis patients, derived from the better knowledge and understanding ofvascular calcification. We analyze the most recent guidelines (K/DOQI), and describethe general implications of hyperphosphatemia, as well as our therapeuticapproach with phosphorus-binders. Since sevelamer additionally presents somepleiotropic effects and it attenuates the progression of vascular calcification, weconsider it in the first-line of treatment despite it is not yet demonstrated a survivalbenefit. We also minimize the use of elemental calcium to a maximum of 1,000to 1,500 mg/day. Lanthanum carbonate may well be an important therapeuticagent in the near future, especially if security concerns related to metal accumulation are overcome. Ferric citrate, colestilan and nicotinamide may soon play arole. All these drugs, isolated or in combination, are important in the treatment ofSHP since a great deal of its success and the avoidance of some dialysis-relatedcomplications depend on an efficient phosphorus controlSecondary hyperparathyroidism (SHP) is a frequent complication of dialysis patients.In this second article we will analyze the new vitamin D analogs, capableof decreasing parathyroid hormone (PTH) levels with a lower effect on intestinalcalcium and phosphorus absorption. Among other advantages described in the experimentalsetting, paricalcitol shows a survival benefit in dialysis patients as comparedto calcitriol, at least in retrospective studies, and thus it became our firstlinevitamin D derivative. Calcimimetics are unique since they decrease PTH levelswithout increasing serum calcium and phosphorus. Actually, calcium and phosphorusdecrease in a significant number of patients. These drugs will soon be authorizedin Spain, and we describe the better achievement of K/DOQI guidelinesas well as other beneficial effects observed in the experimental animal with them.Finally, we mention the potential benefit of mild metabolic acidosis, the use of albisphosphonates,the role of bone morphogenetic protein BMP-7, and the use ofteriparatide. The future treatment of SHP will probably require the independentmanagement of calcium, phosphorus, vitamin D and PTH. Thus, low-dose combinedtreatments with selective drugs may prove more effective than sequential therapies

Nuevas estrategias terapéuticas para el hiperparatiroidismo secundario en diálisis (II): análogos de la vitamina D y calcimiméticos / New therapeutic strategies in secondary hyperparathyroidism on dialysis (II): vitamin d analogues and calcium-mimetics

El hiperparatiroidismo secundario (HPS) sigue siendo una complicación frecuentedel paciente renal. En este segundo artículo se analizarán los análogos dela vitamina D capaces de disminuir la hormona paratiroidea (PTH) pero con menorefecto sobre la absorción de calcio y fósforo intestinal. Aparte de otras ventajasobservadas en el animal experimental, el paricalcitol ha demostrado una mejoríade la supervivencia en relación al calcitriol, al menos en estudios retrospectivos,por lo que lo consideramos el derivado de elección. Los calcimiméticos serán losúnicos fármacos capaces de disminuir la PTH sin inducir aumentos de calcio y/ofósforo séricos. De hecho en un porcentaje notable de estos pacientes, calcio yfósforo disminuyen. Pendientes de su incorporación al mercado español, se describela mejoría de cumplimiento de los objetivos de las guías y sus otros efectosbeneficiosos en el animal experimental. Finalmente se hace mención al potencialbeneficio de la acidosis metabólica leve, el uso de bisfosfonatos, el papel de laproteína morfogenética del hueso BMP-7 y la utilización de teriparatide. El futurode la terapia del HPS probablemente pasa por el manejo independiente de calcio,fósforo (P), vitamina D y PTH, de modo que los tratamientos combinados adosis bajas con drogas selectivas parecen más adecuados que las monoterapiassecuenciales

Secondary hyperparathyroidism (SHP) is still an early and frequent complicationof chronic renal disease (CRD). Currently, CRD is an independent cardiovascularrisk factor, and calcium-phosphorus metabolism is one of the modifiable relatedfactors. In this first article, we summarize the recent SHP treatment paradigmshift in dialysis patients, derived from the better knowledge and understanding ofvascular calcification. We analyze the most recent guidelines (K/DOQI), and describethe general implications of hyperphosphatemia, as well as our therapeuticapproach with phosphorus-binders. Since sevelamer additionally presents somepleiotropic effects and it attenuates the progression of vascular calcification, weconsider it in the first-line of treatment despite it is not yet demonstrated a survivalbenefit. We also minimize the use of elemental calcium to a maximum of 1,000to 1,500 mg/day. Lanthanum carbonate may well be an important therapeuticagent in the near future, especially if security concerns related to metal accumulation are overcome. Ferric citrate, colestilan and nicotinamide may soon play arole. All these drugs, isolated or in combination, are important in the treatment ofSHP since a great deal of its success and the avoidance of some dialysis-relatedcomplications depend on an efficient phosphorus controlSecondary hyperparathyroidism (SHP) is a frequent complication of dialysis patients.In this second article we will analyze the new vitamin D analogs, capableof decreasing parathyroid hormone (PTH) levels with a lower effect on intestinalcalcium and phosphorus absorption. Among other advantages described in the experimentalsetting, paricalcitol shows a survival benefit in dialysis patients as comparedto calcitriol, at least in retrospective studies, and thus it became our firstlinevitamin D derivative. Calcimimetics are unique since they decrease PTH levelswithout increasing serum calcium and phosphorus. Actually, calcium and phosphorusdecrease in a significant number of patients. These drugs will soon be authorizedin Spain, and we describe the better achievement of K/DOQI guidelinesas well as other beneficial effects observed in the experimental animal with them.Finally, we mention the potential benefit of mild metabolic acidosis, the use of albisphosphonates,the role of bone morphogenetic protein BMP-7, and the use ofteriparatide. The future treatment of SHP will probably require the independentmanagement of calcium, phosphorus, vitamin D and PTH. Thus, low-dose combinedtreatments with selective drugs may prove more effective than sequential therapies

Nuevos conceptos sobre la enfermedad renal crónica y sus implicaciones / No disponible

La National Kidney Foundation americana ha definido recientemente criterios que definen un nuevo concepto denominado enfermedad renal crónica. Más o menos discutibles, suponen un importante método de estandarización de rápida aceptación internacional. En este artículo se revisa la nueva definición y estadios, los métodos de diagnóstico y evaluación, sus complicaciones y asociaciones, así como sus factores de progresión a estadios terminales con necesidad de tratamiento sustitutivo. Asimismo se establece el importante nuevo vínculo de la enfermedad renal crónica como factor de riesgo cardiovascular (AU)

The American National Kidney Foundation has recently defined new criteria to define the concept of chronic Kidney disease (CKD). Althougt they are partially under discussion, they have become a very helpful way of standarization and widely internationally accepted. In this article, we review the new definition and stages, the diagnostic and evaluation methods, complications and associations, as well as progression factors to end stage renal disease. It is also underlined the important newly recognized link between chronic kidney disease and cardiovascular risk (AU)

Risk factors for cardiovascular disease after renal transplantation.

Cardiovascular diseases (CVD) have become the leading cause of mortality in renal transplant recipients. Well-known cardiovascular (CV) risk factors and graft dysfunction both play an important role in the development of the posttransplantation CV events. We studied 233 stable kidney transplant patients to establish the prevalence of CVD and to assess CV risk factors that can be evaluated (and modified) in daily clinical practice. While 6.2% of the patients had coronary heart disease (CHD) before the transplantation, 16% displayed at least 1 CV event posttransplantation. The most significant factors associated with CV events were as follows: gender, length of smoking, diabetes mellitus, hepatitis C virus antibodies (HCV), dyslipidemia, proteinuria, and serum creatinine levels.