Diagnosis and Treatment of Secondary Hyperparathyroidism in Pre-Dialysis Stages G3-G4 Chronic Kidney Disease: A Specialized Survey in Portugal
DOI:
https://doi.org/10.71749/pkj.23Keywords:
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.
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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.
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The data presented in this single-round Delphi-like study are available on request from the corresponding author.
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Copyright (c) 2024 Ana Carina Ferreira, Sandra Brum, Luis Coentrão, Edgar Almeida (Author)
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