Diagnosis and Treatment of Secondary Hyperparathyroidism in Pre-Dialysis Stages G3-G4 Chronic Kidney Disease: A Specialized Survey in Portugal
Keywords:
Hyperparathyroidism, Secondary/diagnosis, Hyperparathyroidism, Secondary/therapy, Renal Insufficiency, Chronic, Surveys and Questionnaires, Vitamin D DeficiencyAbstract
Introduction: The clinical management of secondary hyperparathyroidism (SHPT) in chronic kidney disease (CKD) stages G3-G4 patients currently faces several challenges. Although the understanding of SHPT has increased exponentially in recent years, many aspects regarding its diagnosis and management in non-dialysis G3-G4 CKD remain elusive. Specifically, while it is known that SHPT is linked to vitamin D insufficiency in pre-dialysis CKD patients, the target levels of vitamin D and parathyroid hormone, SHPT, and vitamin D monitoring and therapeutic guidelines are still to be clarified. It is, consequently, of utmost importance to generate data supporting consensual clinical decision-making and the implementation of evidence-based clinical practice guidelines.Methods: Thus, a single-round Delphi-like study was conducted herein to assess the opinions and the level of agreement of 59 Portuguese nephrologists on the diagnosis and treatment of pre-dialysis G3-G4 CKD patients with SHPT. Results: Although none of the statements under analysis gathered consensus, more than half of the statements regarding SHPT monitoring and therapeutics focusing on G3-G4 CKD achieved a qualified majority of agreement/disagreement. Overall, it may indicate a growing consensus trend among Portuguese nephrology specialists. Conversely, the heterogeneity of participants’ opinions regarding the treatment of SHPT-associated vitamin D insufficiency reflects the heterogeneity in the knowledge in this specific field.
Conclusion: The results from this Delphi-like panel represent a first step towards improving the monitoring and therapeutic strategies concerning the prognosis of G3-G4 CKD patients, fostering unison among the Portuguese nephrology community.
Downloads
References
Cunningham J, Locatelli F, Rodriguez M. Secondary hyperparathyroidism: pathogenesis, disease progression, and therapeutic options. Clin J Am Soc Nephrol. 2011;6:913-21. doi: 10.2215/CJN.06040710.
Habas E Sr, Eledrisi M, Khan F, Elzouki AY. Secondary Hyperparathyroidism in Chronic Kidney Disease: Pathophysiology and Management. Cureus. 2021;13:e16388. doi: 10.7759/cureus.16388.
Wolf M. Forging forward with 10 burning questions on FGF23 in kidney disease. J Am Soc Nephrol, 2010; 21:1427-35. doi: 10.1681/ ASN.2009121293.
Rouached M, El Kadiri Boutchich S, Al Rifai AM, Garabédian M, Fournier A. Prevalence of abnormal serum vitamin D, PTH, calcium, and phosphorus in patients with chronic kidney disease: results of the study to evaluate early kidney disease. Kidney Int. 2008;74:38990. doi: 10.1038/ki.2008.169.
Stavroulopoulos A, Porter CJ, Roe SD, Hosking DJ, Cassidy MJ. Relationship between vitamin D status, parathyroid hormone levels and bone mineral density in patients with chronic kidney disease stages 3 and 4. Nephrology 2008;13:63-7. doi: 10.1111/j.1440-1797.2007.00860.x.
Andress DL, Coyne DW, Kalantar-Zadeh K, Molitch ME, Zangeneh F, Sprague SM. Management of secondary hyperparathyroidism in stages 3 and 4 chronic kidney disease. Endocr Pract. 2008;14:18-27. doi: 10.4158/EP.14.1.18.
Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Work Group. KDIGO clinical practice guideline for the diagnosis, evaluation, prevention, and treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD). Kidney Int Suppl. 2009;113:S1-130. doi: 10.1038/ki.2009.188.
Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Update Work Group. KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD). Kidney Int Suppl. 2017;7:1-59. doi: 10.1016/j.kisu.2017.04.001.
Keung L, Perwad F. Vitamin D and kidney disease. Bone Rep. 2018;9:93-100. doi: 10.1016/j.bonr.2018.07.002. Erratum in: Bone Rep. 2021;14:101084.
Rodríguez-Ortiz ME, Rodríguez M. Recent advances in understanding and managing secondary hyperparathyroidism in chronic kidney disease. F1000Res. 2020;9:F1000 Faculty Rev-1077. doi: 10.12688/ f1000research.22636.1.
National Kidney Foundation. K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis. 2003;42:S1-201.
Doorenbos CR, van den Born J, Navis G, de Borst MH. Possible renoprotection by vitamin D in chronic renal disease: beyond min‐ eral metabolism. Nat Rev Nephrol. 2009;5:691-700. doi: 10.1038/ nrneph.2009.185.
Kim CS. Sp368chronic Kidney Disease Mineral Bone Disorder in Korean Patients a Report from the Know-Ckd. Nephrol Dial Transplant. 2017;32:iii236-iii236.
Brandenburg V, Ketteler M. Vitamin D and Secondary Hyperparathyroidism in Chronic Kidney Disease: A Critical Appraisal of the Past, Present, and the Future. Nutrients. 2022;14:3009. doi: 10.3390/ nu14153009.
Con: Nutritional vitamin D replacement in chronic kidney disease and end-stage renal disease. Nephrol Dial Transplant. 2021;36:5667. doi: 10.1093/ndt/gfaa172. Erratum for: Nephrol Dial Transplant. 2016;31:706-13.
Roizen JD, Long C, Casella A, O’Lear L, Caplan I, Lai M, et al. Obesity Decreases Hepatic 25-Hydroxylase Activity Causing Low Serum 25-Hydroxyvitamin D. J Bone Miner Res. 2019;34:1068-73. doi: 10.1002/jbmr.3686.
De Pergola G, Martino T, Zupo R, Caccavo D, Pecorella C, Paradiso S, et al. 25 Hydroxyvitamin D Levels are Negatively and Independent‐ ly Associated with Fat Mass in a Cohort of Healthy Overweight and Obese Subjects. Endocr Metab Immune Disord Drug Targets. 2019;19:838-44. doi: 10.2174/1871530319666190122094039.
Saneei P, Salehi-Abargouei A, Esmaillzadeh A. Serum 25-hydroxy vitamin D levels in relation to body mass index: a systematic review and meta-analysis. Obes Rev. 2013;14:393-404. doi: 10.1111/obr.12016..
Tebben PJ, Singh RJ, Kumar R. Vitamin D-Mediated Hypercalcemia: Mechanisms, Diagnosis, and Treatment. Endocr Rev. 2016;37:52147. doi: 10.1210/er.2016-1070.
Petkovich M, Melnick J, White J, Tabash S, Strugnell S, Bishop CW. Modified-release oral calcifediol corrects vitamin D insufficiency with minimal CYP24A1 upregulation. J Steroid Biochem Mol Biol. 2015;148:283-9. doi: 10.1016/j.jsbmb.2014.11.022.
Sprague SM, Crawford PW, Melnick JZ, Strugnell SA, Ali S, Mangoo-Karim R, et al. Use of Extended-Release Calcifediol to Treat Secondary Hyperparathyroidism in Stages 3 and 4 Chronic Kidney Disease. Am J Nephrol. 2016;44:316-25. doi: 10.1159/000450766.
Sprague SM, Strugnell SA, Bishop CW. Extended-release calcifediol for secondary hyperparathyroidism in stage 3‐4 chronic kidney disease. Expert Rev Endocrinol Metab. 2017;12:289-301. doi: 10.1080/17446651.2017.1347501.
Sprague SM, Silva AL, Al‐Saghir F, Damle R, Tabash SP, Petkovich M, et al. Modified-release calcifediol effectively controls secondary hyperparathyroidism associated with vitamin D insufficiency in chronic kidney disease. Am J Nephrol. 2014;40:535-45. doi: 10.1159/000369939. .
Strugnell SA, Sprague SM, Ashfaq A, Petkovich M, Bishop CW. Rationale for Raising Current Clinical Practice Guideline Target for Serum 25-Hydroxyvitamin D in Chronic Kidney Disease. Am J Nephrol. 2019;49:284-293. doi: 10.1159/000499187.
Ennis JL, Worcester EM, Coe FL, Sprague SM. Current recommended 25-hydroxyvitamin D targets for chronic kidney disease management may be too low. J Nephrol. 2016;29:63-70. doi: 10.1007/ s40620-015-0186-0.
Nemeth EF. Pharmacological regulation of parathyroid hormone secretion. Curr Pharm Des. 2002;8:2077-87. doi: 10.2174/1381612023393387.
Chonchol M, Locatelli F, Abboud HE, Charytan C, de Francisco AL, Jolly S, et al. A randomized, double‐blind, placebo‐controlled study to assess the efficacy and safety of cinacalcet HCl in participants with CKD not receiving dialysis. Am J Kidney Dis. 2009;53:197-207. doi: 10.1053/j.ajkd.2008.09.021.
Tomasello S. Secondary Hyperparathyroidism and Chronic Kidney Disease. Diabetes Spect. 2008;21:19-25. 2008.
Cernaro V, Santoro D, Lacquaniti A, Costantino G, Visconti L, Buemi A, et al. Phosphate binders for the treatment of chronic kidney disease: role of iron oxyhydroxide. Int J Nephrol Renovasc Dis. 2016;9:11-9. doi: 10.2147/IJNRD.S78040.
Thadhani R, Appelbaum E, Pritchett Y, Chang Y, Wenger J, Tamez H, et al. Vitamin D therapy and cardiac structure and function in patients with chronic kidney disease: the PRIMO randomized controlled trial. JAMA. 2012;307:674-84. doi: 10.1001/jama.2012.120.
Wang AY, Fang F, Chan J, Wen YY, Qing S, Chan IH, et al. Effect of paricalcitol on left ventricular mass and function in CKD--the OPERA trial. J Am Soc Nephrol. 2014;25175-86. doi: 10.1681/ASN.2013010103. Erratum in: J Am Soc Nephrol. 2019;30:516.
Ashfaq A, Germain MJ, Paul SK, Broumand V, Fadda G, Nguyen A, et al. P0901real-World Assessment: Clinical Effectiveness and Safety of Vitamin D Therapies in Nd-Ckd Patients. Nephrol Dial Transplant. 2020;35:gfaa142.P0901, https://doi.org/10.1093/ndt/gfaa142. P0901
Cozzolino M, Ketteler M. Evaluating extended-release calcifediol as a treatment option for chronic kidney disease-mineral and bone disorder (CKD-MBD). Expert Opin Pharmacother. 2019;20:2081-93. doi: 10.1080/14656566.2019.1663826.
Cook S, Aikens JE, Berry CA, McNabb WL. Development of the di‐ abetes problem‐solving measure for adolescents. Diabetes Educ. 2001;27:865-74. doi: 10.1177/014572170102700612.
Crane D, Henderson EJ, Chadwick DR. Exploring the acceptability of a ‘limited patient consent procedure’ for a proposed blood-borne virus screening programme: a Delphi consensus building technique. BMJ Open. 2017;7:e015373. doi: 10.1136/bmjopen-2016-015373.
Rose CM, Kagan AR. The final report of the expert panel for the radiation oncology bone metastasis work group of the American College of Radiology. Int J Radiat Oncol Biol Phys. 1998;40:1117-24.
Wainwright P, Gallagher A, Tompsett H, Atkins C. The use of vignettes within a Delphi exercise: a useful approach in empirical ethics? J Med Ethics. 201036:656-60. doi: 10.1136/jme.2010.036616.
Wigton RS, Darr CA, Corbett KK, Nickol DR, Gonzales R. How do community practitioners decide whether to prescribe antibiotics for acute respiratory tract infections? J Gen Intern Med. 2008;23:161520. doi: 10.1007/s11606-008-0707-9.
Taylor E. We Agree, Don’t We? The Delphi Method for Health Environments Research. HERD. 2020;13:11-23. doi: 10.1177/1937586719887709.
Downloads
Published
Data Availability Statement
The data presented in this single-round Delphi-like study are available on request from the corresponding author.
Issue
Section
License
Copyright (c) 2024 Ana Carina Ferreira, Sandra Brum, Luis Coentrão, Edgar Almeida (Author)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
