Background. The purpose of the present study was to evaluate the impact of cinacalcet administration on the attainment of Kidney Disease Outcomes Quality Initiative of the National Kidney Foundation (NFK-K/DOQI) targets, in a group of dialysis patients with secondary hyperparathyroidism that were not controlled with vitamin D metabolites due to inadequate elevations in serum calcium and/or phosphorus. Methods. Twenty-eight patients undergoing haemodialysis that presented secondary hyperparathyroidism (PTH > 300 pg/ml) with difficulty to use vitamin D either because of hypercalcaemia (>10.2 mg/dl) and/or hyperphosphoraemia (>5.5 mg/dl) were included in this study. The follow-up period was 9 months before and after the introduction of cinacalcet. We started by adding 30 mg of cinacalcet orally once daily to their previous vitamin D metabolite treatment. The following variables were calculated and recorded: the mean of all measurements of serum Ca, P and parathyroid hormones (PTH), and Ca × P in each patient; calcium in dialysate (mEq/l); doses of vitamin D administered; doses of cinacalcet used, and the average prescription of calcium–based phosphate binders, sevelamer hydrochloride and aluminum binders, corresponding to two periods according to the introduction of cinacalcet. The proportions of patients with different serum Ca levels as well as serum P levels; serum PTH levels and CaxP at the beginning and at the end of the nine month period of treatment with cinacalcet were calculated. Results. Serum PTH (826.9 ± 325 vs 248.1 ± 77.3, P < 0.001), serum calcium (9.9 ± 0.6 vs 8.6 ± 0.4, P < 0.001) and the Ca × P product (94.7 ± 7.3 vs 43.6 ± 8.5; P < 0.001) diminished significantly whereas serum phosphorus remained unchanged (4.8 ± 1.5 vs 4.3 ± 1.1; P = NS). Before cinacalcet, 23 patients had severe hyperparathiroidism (serum PTH > 500) and 15 patients hypercalcaemia (serum calcium >10.2 mg/dl). After 9 months of treatment, all 28 patients showed serum PTH < 500 pg/ml and serum calcium <10.2 mg/dl; 64.7% of the patients achieved Ca, P, Ca × P and PTH objectives simultaneously. While the mean dose of cinacalcet increased along the 9 months of treatment ( P < 0.001), there were no significant changes in vitamin D metabolites ( P = 0.5), neither in the mean doses of calcium-containing agents, nor in the mean prescribed doses of sevelamer ( P < 0.01), and aluminium-containing agents diminished significantly ( P < 0.05). Conclusions. In summary, the combination of cinacalcet and low doses of vitamin D improved significantly the control of PTH and Ca × P in patients with severe secondary hyperparathiroidism on chronic haemodialysis, without adverse effects and with lower doses of phosphate binders.

Cinacalcet induces immediate changes in serum PTH levels, but the pharmacodynamic effect throughout the daily dosing interval in controlled patients is unknown. Also, in patients with reduced PTH, it is unknown what happens in the first 24 hours after withdrawal. Our aim was to describe the effect over 48 hours of cinacalcet in hemodialysis patients with controlled secondary hyperparathyroidism. This was a phase 4, open-label, single-arm, single-dose, single-center clinical trial. The study was conducted at a public hospital (Hospital Perpetuo Socorro, Alicante, Spain). We included 10 patients on cinacalcet for 6 months or longer with intact PTH (iPTH) levels 100-400 pg/mL [8 men, mean age of 66 years (range 39-82 years)], chronically treated with 30 mg (n = 6), 60 mg (n = 3), or 90 mg (n = 1) of cinacalcet. A single dose (30-90 mg) was administered at baseline. iPTH (Duo Kit Scantibodies and Elecsys Roche), PTH 1-84, ionized calcium, phosphorus (P), and calcitonin were determined at baseline and at 1, 3, 6, 12, 24, and 48 hours. There was a significant reduction in iPTH between 1 and 6 hours, and values returned to baseline at 24 hours [maximum mean (95% confidence interval) percent change from baseline: -50%(-34; -66) at 3 hours]. A transient increase in calcitonin and a decrease in P were also observed, with no changes in calcium. At 48 hours, there was a significant increase in iPTH [+51% (26; 76)] and P. Changes in PTH were similar with the 3 determination methods. In hemodialysis patients with secondary hyperparathyroidism controlled by cinacalcet, a transient (1-6 hours) reduction in PTH and P and an increase in calcitonin are observed after each daily dose, with return to baseline at 24 hours. After calcimimetics discontinuation, PTH was significantly increased at 48 hours. The assay used to measure PTH does not influence relative changes induced by cinacalcet.

Calcific uremic arteriolopathy (CUA) is a rare but serious complication of end-stage renal disease presenting as painful cutaneous lesions and progressing to non-healing ulcers and gangrene. This syndrome is associated with calcium and phosphorus deposits within small arteries of the skin. The pathognomonic lesion is vascular calcification with intimal arterial hypertrophy and superimposed small-vessel thrombosis. The condition is being increasingly recognized and reported as a contributing factor to death in dialysis patients, with secondary infection and sepsis as the major cause of mortality. No standard treatment has been established for this syndrome. We present the therapeutic approach employed in two patients, which successfully resulted in healing of the lesions, using a combination of measures to control the factors potentially related to development of CUA and hyperbaric oxygen therapy.

Chronic kidney disease–associated pruritus is itching directly related to kidney disease that cannot be explained by any other condition. Despite technological advances in the different aspects of dialysis sessions and the best treatment for chronic kidney disease patients, it is still a common problem in our patients. The many complex physiological mechanisms involved, the different hypotheses made over the years on the aetiology of the condition, and the great clinical variability may partially explain the limited knowledge about this problem and the difficulties in treating it. The presence of all these factors leads to the persistence of unpleasant symptoms, which must affect the disease burden and quality of life of kidney patients. Through the presentation of an illustrative clinical case, the aim of this review article is to highlight the need for adequate diagnosis and an improved approach to all aspects of chronic kidney disease–associated pruritus, in view of the heavy burden of the disease and the huge impact on the patient’s quality of life.

Instrumental Activities of Daily Life (IADL) requires a higher level of personal autonomy and interaction with the environment than the basic activities of daily life (BADL). Few studies analyze the deficit on IADL. Early detection is important because an early action can delay the evolution of the dependency process. to know the prevalence of functional deficit in IADL of hemodialysis patients, its relationship with the functional deficit in the BADL and its influence on the health related quality of life (HRQoL). Cross-sectional study in 66 patients on HD. Different scales were used: Lawton and Brody (AIVD dependency), Delta (BADL dependency), and COOP-WONCA (HRQOL). Clinical data were collected (age, sex, CKD etiology, months in HD, marital status, employment situation). 80.3% of the patients had some degree of dependence for the IADL (57.5% in moderate/severe degree) and 40.8% for the BADL (9% in moderate/severe degree). There was a correlation between dependence to the BADL and AIVD. Age and employment status influence the dependence on IADL and BADL. Patients with greater dependence on IADL had worse HRQoL (P<.000). The dimensions in which they showed greater differences were "Daily activities", "Social activities" and "Social support". HD patients are more dependent on IADL than on ADL and with a higher degree of severity and the level of dependence in both types of activities has important influence on HRQoL. Early detection of the occurrence of disability in the realization of IADL can be used to initiate intervention programs that help to prevent, reverse or delay the progression.

Background. In COVID-19 patients, low serum vitamin D (VD) levels have been associated with severe acute respiratory failure and poor prognosis. In regular hemodialysis (HD) patients, there is VD deficiency and markedly reduced calcitriol levels, which may predispose them to worse outcomes of COVID-19 infection. Some hemodialysis patients receive treatment with drugs for secondary hyperparathyroidism, which have well known pleiotropic effects beyond mineral metabolism. The aim of this study was to evaluate the impact of VD status and the administration of active vitamin D medications, used to treat secondary hyperparathyroidism, on survival in a cohort of COVID-19 positive HD patients. Methods. A cross-sectional retrospective observational study was conducted from 12 March to 21 May 2020 in 288 HD patients with positive PCR for SARS-CoV2. Patients were from 52 different centers in Spain. Results. The percent of HD patients with COVID-19 was 6.1% (288 out of 4743). Mortality rate was 28.4% (81/285). Three patients were lost to follow-up. Serum 25(OH)D (calcidiol) level was 17.1 [10.6–27.5] ng/mL and was not significantly associated to mortality (OR 0.99 (0.97–1.01), p = 0.4). Patients receiving active vitamin D medications (16/94 (17%) vs. 65/191(34%), p = 0.003), including calcimimetics (4/49 (8.2%) vs. 77/236 (32.6%), p = 0.001), paricalcitol or calcimimetics (19/117 (16.2%) vs. 62/168 (36.9%); p < 0.001), and also those on both paricalcitol and calcimimetics, to treat secondary hyperparathyroidism (SHPTH) (1/26 (3.8%) vs. 80/259 (30.9%), p < 0.001) showed a lower mortality rate than patients receiving no treatment with either drug. Multivariate Cox regression analysis confirmed this increased survival. Conclusions. Our findings suggest that the use of paricalcitol, calcimimetics or the combination of both, seem to be associated with the improvement of survival in HD patients with COVID-19. No correlation was found between serum VD levels and prognosis or outcomes in HD patients with COVID-19. Prospective studies and clinical trials are needed to support these findings.