Original article
Use of cinacalcet for the management of hyperparathyroidism in patients with different degrees of renal failure
Uso de cinacalcet para el control del hiperparatiroidismo en pacientes con diferentes grados de insuficiencia renal
José M. Orellanaa,
, Rafael J. Estebana, Yina A. Castillaa, Rafael Fernández-Castillob, Gonzalo Nozal-Fernándezc, María A. Esteband, María García-Valverdea, Juan Bravoa
Corresponding author
a UGC de Nefrología, Hospitales Virgen de las Nieves y Clínico San Cecilio, Granada, Spain
b Facultad de Ciencias de la Salud, Universidad de Granada, Granada, Spain
c UGC de Farmacia, Hospitales Virgen de las Nieves y Clínico San Cecilio, Granada, Spain
d UGC de Churriana, Distrito Sanitario de Granada, Granada, Spain
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"apellidos" => "Esteban" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 6 => array:3 [ "nombre" => "María" "apellidos" => "García-Valverde" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 7 => array:3 [ "nombre" => "Juan" "apellidos" => "Bravo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "UGC de Nefrología, Hospitales Virgen de las Nieves y Clínico San Cecilio, Granada, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Facultad de Ciencias de la Salud, Universidad de Granada, Granada, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "UGC de Farmacia, Hospitales Virgen de las Nieves y Clínico San Cecilio, Granada, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "UGC de Churriana, Distrito Sanitario de Granada, Granada, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Uso de cinacalcet para el control del hiperparatiroidismo en pacientes con diferentes grados de insuficiencia renal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1038 "Ancho" => 1650 "Tamanyo" => 93756 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Percent change in eGFR and in bone and mineral metabolism after treatment with cinacalcet between values at baseline and at 12 months. *Represents statistical significance.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Cinacalcet (Mimpara<span class="elsevierStyleSup">®</span>) is currently the only calcimimetic with an approved indication for the treatment of secondary hyperparathyroidism (SHPT) in patients with chronic kidney disease (CKD) on dialysis,<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">1–3</span></a> as well as in primary hyperparathyroidism (PHPT) caused by parathyroid adenoma or carcinoma in patients who have not undergone a parathyroidectomy, or with persistence of the disease following parathyroidectomy.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a> Also, it has been used successfully in residual SHPT from a kidney transplant, although it does not a formal indication<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">4</span></a> in these patients.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The calcimimetics acts as a positive allosteric modulator of the calcium-sensor receptors expressed in multiple tissues such as the parathyroid glands, kidneys, bone (especially in osteoclasts) and blood vessels.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">5</span></a> Its activation increases signal transduction, presumably inducing intracellular conformational changes and reducing the threshold for calcium sensitivity. At the glandular level, this translates to lower production and secretion of parathyroid hormone (PTH), which is essential in the management of resistant SHPT and SHPT associated with hypercalcaemia in patients in dialysis, in whom it has also shown modification of bone turnover markers.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Less known are the effects of calcimimetics on patients with abnormal renal function not on dialysis, in whom mineral and bone disorder (MBD) associated with CKD is present.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">5–7</span></a> The latter does not strictly include only abnormalities in calcium, phosphorus, PTH and vitamin D; it also comprises abnormalities in bone remodelling, volume and resistance; as well as vascular and soft-tissue calcifications.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">7,8</span></a> In patients with CKD, the determination of collagen degradation products and classic bone turnover markers have greater utility than bone densitometry to predict the risk of fractures. Hence the importance of studying these parameters.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">This work aims to determine the efficacy and safety of cinacalcet in the treatment of SHPT in patients with CKD not treated with renal replacement therapy, in whom, owing to their serum calcium levels, the use of vitamin D and its derivatives is not safe, and in patients with severe hyperparathyroidism with a contraindication for surgery. It also aims to describe its effects on bone remodelling markers.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Patients and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">We conducted an observational, longitudinal study in a cohort of patients followed in our outpatient clinics. Patients enrolled had a diagnosis of SHPT (iPTH level<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>80<span class="elsevierStyleHsp" style=""></span>pg/ml), whether with hypercalcaemia (which limited the use of both calcium-chelating agents and vitamin D and its analogues) or with normocalcaemia (corrected calcium ≥8.5<span class="elsevierStyleHsp" style=""></span>mg/dl) resistant to these treatments. Patients were on stages 3–5 CKD (estimated glomerular filtration rate [eGFR] between 60 and <15<span class="elsevierStyleHsp" style=""></span>ml/min/1.73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>).</p><p id="par0030" class="elsevierStylePara elsevierViewall">The sociodemographic variables of the sample were recorded.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In each patient the use of cinacalcet for compassionate use was requested and authorised.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patients started treatment with cinacalcet at a dose of 30<span class="elsevierStyleHsp" style=""></span>mg in a single dose taken in the morning, and the dose was adjusted according to the evolution of the measured parameters.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The eGFR was calculated using the MDRD-4 formula, and iPTH, calcium, phosphorus, osteocalcin (OC), total alkaline phosphatase (AP), beta-crosslaps (β-CTX) and P1NP levels were determined using our laboratory's standard techniques.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">9</span></a> These variables were recorded at baseline, 6 months and 12 months from the start date of treatment with cinacalcet. We recorded adverse reactions and suspensions of this treatment, as well as associated medication based on phosphorus-chelating agents (both calcium and non-calcium), vitamin D analogues and biphosphonates.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The discrete variables were summarised using frequencies and percentages, and continuous variables were summarised using means<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>standard deviations (SDs), medians and percentiles (P25 and P75). The analysis was performed with the greatest number of subjects with observed and recorded data for each variable, since lost values were not replaced; in all cases it was always <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>9. We used Friedman's 2-way analysis to study the change in the variables at baseline, 6 months and 12 months, and the Wilcoxon signed-rank test for the change after a year. The statistical analyses were performed using the IBM<span class="elsevierStyleSup">®</span> SPSS<span class="elsevierStyleSup">®</span> Statistics v. 19 software program. The level of significance was set at <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">A total of 15 patients were enrolled; 10 were women, and the mean age was 66.0<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>17.9 years. They were distributed as CKD 3 (8 patients), CKD4 (3 patients) and CKD 5 (4 patients). The cause of CKD was vascular (7 patients), glomerular (3 patients), interstitial (one patient), diabetic (one patient) or of unknown origin (4 patients).</p><p id="par0060" class="elsevierStylePara elsevierViewall">Before starting treatment with cinacalcet, 50.0% of patients were taking paricalcitol, 13.3% were taking non-calcium phosphorus-chelating agents and 26.6% were taking biphosphonates; these agents were continued. The starting dose of cinacalcet in most patients was 30<span class="elsevierStyleHsp" style=""></span>mg/day, and after a year the mean dose of cinacalcet was 36.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>14.1<span class="elsevierStyleHsp" style=""></span>mg/24<span class="elsevierStyleHsp" style=""></span>h.</p><p id="par0065" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the evolution of eGFR and bone and mineral metabolism parameters following the treatment with cinacalcet, as well as the results of the comparisons performed.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Before therapy the mean iPTH was 392.4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>317.6, and mean blood calcium concentration was 10.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.5<span class="elsevierStyleHsp" style=""></span>mg/dl. After 12 months of treatment he PTH levels decrease by 64% (Mean<span class="elsevierStyleInf">12 months</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>141.8) that was statistically significant as compared with baseline (Friedman, <span class="elsevierStyleItalic">χ</span><span class="elsevierStyleSup">2</span>(2)<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>8.222; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.016; Wilcoxon, <span class="elsevierStyleItalic">Z</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>−2.599; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.009). The values of serum calcium decreased by 9.0% (Mean<span class="elsevierStyleInf">12 months</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>9.4<span class="elsevierStyleHsp" style=""></span>mg/dl) this fall was significant as compared with baseline, (Friedman, <span class="elsevierStyleItalic">χ</span><span class="elsevierStyleSup">2</span>(2)<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>7.800; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.02; Wilcoxon, <span class="elsevierStyleItalic">Z</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>−2.832; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.005) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> and <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">We also observed a 5.0% increase in the mean serum phosphorus concentration after the one year of treatment (Mean<span class="elsevierStyleInf">12 months</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>3.9<span class="elsevierStyleHsp" style=""></span>mg/dl) as compared with the baseline values (Mean<span class="elsevierStyleInf">Baseline</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>3.7<span class="elsevierStyleHsp" style=""></span>mg/dl); this was not statistically significant according to Friedman, <span class="elsevierStyleItalic">χ</span><span class="elsevierStyleSup">2</span>(2)<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>5.250; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.072, although it was significant according to Wilcoxon, <span class="elsevierStyleItalic">Z</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>−2.599; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.011. We also found a 19.0% increase in the levels of the bone resorption marker β-CTX after 12 months (Mean<span class="elsevierStyleInf">12</span><span class="elsevierStyleInf">months</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1053<span class="elsevierStyleHsp" style=""></span>pg/ml) compared with the baseline CTX values (Mean<span class="elsevierStyleInf">Baseline</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>885<span class="elsevierStyleHsp" style=""></span>pg/ml); this change was significant according to the Wilcoxon rank test (<span class="elsevierStyleItalic">Z</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>−2.045; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.041); but did not reach statistical significance according to Friedman, <span class="elsevierStyleItalic">χ</span><span class="elsevierStyleSup">2</span>(2)<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1.000; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.607. There were no significant differences in the mean values for calciuria, eGFR, OC, P1NP or AP.</p><p id="par0080" class="elsevierStylePara elsevierViewall">In two patients (13.3%) cinacalcet was discontinued: one due to gastrointestinal intolerance and the other patient because parathyroidectomy.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">Our pilot study has demonstrated that cinacalcet is effective in the management of SHPT associated with CKD in patients not yet in dialysis PTH levels decreased togheter with a reduction in serum calcium levels without detection of serious adverse events.</p><p id="par0090" class="elsevierStylePara elsevierViewall">SHPT and MBD are present in patients with CKD.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">1,3,5–7</span></a> Both clinical conditions involve a substantial healthcare burden owing to their broad association with increase in cardiovascular risk, mortality and onset of fractures.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">3,5,8</span></a> Some studies even highlighted the differential involvement of each MBD factor in mortality (calcium/mortality<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>phosphorus/mortality<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>PTH/mortality ratio).<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">3,8</span></a> In patients with CKD management of SHPT and MBD is made by controlling the triggering factors: through dietary restriction of phosphorus, the use of both calcium and non-calcium chelating agents, and correction of deficiencies such as vitamin D (or its analogues).<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">3,6,10</span></a> On occasion, the above-mentioned measures are not effectve, and may be even have adverse effects as they increase the risk of vascular or soft-tissue calcifications in patients with high baseline blood calcium levels.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">5,11</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Calcimimetics offer a therapeutic advantage as they act on the main physiopathological factors of both entities, which are already broadly related. Firstly, they reduce serum levels of PTH by decreasing its gene expression and secondly, they stimulate the synthesis of vitamin D receptors in the parathyroid gland, thereby increasing sensitivity to vitamini D with the subsequent PTH suppression.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">2,5,6,12,13</span></a> Some studies demonstrate tha cacimimetics stimulate calcitonin, which would cause a reduction in serum calcium levels. Regarding the serum phosphorus concentration, it is known that with GFR<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>ml/min/1.73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>, there is an increase in the serum concentration of the phosphaturic hormone FGF-23, that also inhibits calcitriol synthesis.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">2,3</span></a> The increase in FGF23 is considered a physiological adaptation aimed to maintain better controlled phosphorus levels until advanced stages of CKD.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">3</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">There is limited informatio on the effect of cinacalcet in CKD outside of dialysis. To the best of our knowledge thera are two studies,<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">4,5</span></a> neither of which investigates the effects of the drug in early stages of CKD or the effects on calcimimetics on bone remodelling. Therefore, our findings will be novel. We found that, after one year of cinacalcet in patients with stage 3–5 CKD (KDOQI), the serum iPTH levels significantly decreased, by around 65%, and serum calcium levels was reduced by almost 10% from baseline values. The above results match the observations in dialysis patients.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">1,5,12</span></a> There is considerable correlation between the reduction of PTH in dialysis and in CKD patients.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">1,3,11</span></a> However, there were discordant results with respect to serum levels of phosphorus and β-CTX which in dialyisi patients are normally reduced acter calcimimetics treatment.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">8,10–13</span></a> Therefore, the outcomes did not correspond to the respective 5% and 19% increases that our cohort presented. This latter results are probably explained by the reducton in PTH that deprive patients with significant GFR from the phosphaturic effects of PTH, in addition to the implication of cinacalcet in the reduction of FGF-23 levels.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">12</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Bone remodelling markers are a dynamic reflection of the synthesis/degradation activity of the entire skeleton; this is different from densitometry/radiography, which focus on a static part of bone activity. Under normal conditions, the bone remodelling cycle last 3–6 months. Degradation of type <span class="elsevierStyleSmallCaps">I</span> collagen results in blood and urine detection of both aminoxy terminal and carboxy terminal portions.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a> There are more specific markers of bone formation, some are related to osteoblast activity (OC, P1NP and AP) and others are more related to bone resorption and osteoclast activity (ICTP, CTX and NTX).<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a> Their usefulness is based on the determination of the rate of bone turnover and risk of fractures and their function as a prognostic factor for response to treatment of metabolic bone diseases.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">7,14</span></a> However, to assess bone health, biopsy and tetracycline labelling remain the gold standard.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">7,14</span></a> β-CTX monitoring is useful in verifying response to antiresorptive therapy; the higher the initial values of this marker, the greater the response.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">1,6,7,12</span></a> The evolution of β-CTX levels did not correspond to what had been observed in previous works conducted in hemodialysis patients on cinacalcet<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a>; however, we do not have studies in patients with CKD not in dialysis. It should be mentioned that around 27% of the patients included in our study were treated with antiresorptive agents, as they had GFR greater than 30<span class="elsevierStyleHsp" style=""></span>ml/min. We are not certain whether there are implications associated with the use of cinacalcet and our findings. We believe that this subject should be further explored.</p><p id="par0110" class="elsevierStylePara elsevierViewall">We did not observe any trends towards improvement of GFR, or changes in calciuria therefore the reduction in serum calcium concentration should not be related to urine losses.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Our conclusions may be limited by the small number of patients and the method of data collection which can lead to selection or information bias.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusion</span><p id="par0120" class="elsevierStylePara elsevierViewall">Cinacalcet effectively decreases iPTH and calcium levels in patients with CKD not in renal replacement therapy. Safety is similar to the observed in dialysis patients; no adverse effects occurred during the observation period. No significant variation in renal function was observed. It was observed an increase in serum phosphate and bone resorption marker β-CTX.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflicts of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres822449" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objectives" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec819296" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres822450" "titulo" => "Resumen" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec819295" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Patients and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-05-14" "fechaAceptado" => "2015-10-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec819296" "palabras" => array:7 [ 0 => "Cinacalcet" 1 => "Chronic kidney disease" 2 => "Secondary hyperparathyroidism" 3 => "Parathyroid hormone" 4 => "Calcium" 5 => "Phosphorus" 6 => "Bone turnover markers" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec819295" "palabras" => array:7 [ 0 => "Cinacalcet" 1 => "Enfermedad renal crónica" 2 => "Hiperparatiroidismo secundario" 3 => "Hormona paratiroidea" 4 => "Calcio" 5 => "Fósforo" 6 => "Marcadores de recambio óseo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The effects of cinacalcet in persistent and/or hypercalcaemia-associated secondary hyperparathyroidism (SHPT) have been described in patients on dialysis.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objectives</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To evaluate the efficacy and safety of cinacalcet in SHPT not on dialysis and its effects on bone turnover markers.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Non-randomised, longitudinal, observational, analytical study of patients with chronic kidney disease (CKD) and SHPT (PTH >80<span class="elsevierStyleHsp" style=""></span>pg/mL) as well as normo- or hypercalcaemia (≥8.5<span class="elsevierStyleHsp" style=""></span>mg/dL), treated with cinacalcet.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Mean cinacalcet dose was 30<span class="elsevierStyleHsp" style=""></span>mg/day in 66.7%. We studied 15 patients (10 women), aged 66.0<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>17.93 years. The aetiology was unknown in 20% of cases. Sociodemographic variables and renal function parameters were recorded. We compared values at baseline as well as after 6 and 12 months. Calcium (10.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.55 vs. 9.4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.04) and iPTH (392.4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>317.65 vs. 141.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>59.26) levels decreased. Increased levels of phosphorus (3.7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.06 vs. 3.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.85) and β-CTX (884.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>797.22 vs. 1053.6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>999.00) were detected, although there were no significant changes in GFR, urinary calcium or other bone markers. Two patients withdrew from the study (gastrointestinal intolerance and parathyroidectomy, respectively).</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Cinacalcet at low doses is effective in the management of SHPT in CKD patients who are not on dialysis. Its use reduces iPTH and calcaemia, without causing serious side effects or significant changes in renal function.</p></span>" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objectives" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Antecedentes</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Los efectos de cinacalcet en el hiperparatiroidismo secundario (HPTS), persistente o asociado a hipercalcemia han sido descritos en pacientes en diálisis.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Analizar la eficacia y seguridad de cinacalcet en HPTS no sometido a diálisis y sus efectos sobre marcadores de recambio óseo.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Métodos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Estudio analítico observacional, no aleatorizado, longitudinal, de pacientes con enfermedad renal crónica (ERC) e HPTS (PTH > 80<span class="elsevierStyleHsp" style=""></span>pg/mL); con normohipercalcemia (≥8,5<span class="elsevierStyleHsp" style=""></span>mg/dL), tratados con cinacalcet.</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">La dosis media de cinacalcet fue de 30<span class="elsevierStyleHsp" style=""></span>mg/día en un 66,7%. Estudiamos 15 pacientes (10 mujeres), con edad de 66,0<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>17,93 años. Etiología desconocida en 20% de los casos. Registramos variables sociodemográficas y parámetros de función renal. Comparamos valores basales, tras 6 y 12 meses. Descendieron los niveles de iPTH (392,4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>317,65 vs. 141,8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>59,26) y calcio (10,3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0,55 vs. 9,4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1,04). Aumentaron los valores de fósforo (3,7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1,06 vs. 3,9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0,85) y ß-CTX (884,2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>797,22 vs. 1.053,6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>999,00), sin variaciones significativas del FG, calciuria y demás marcadores óseos. Registrados 2 abandonos (intolerancia digestiva y paratiroidectomía, respectivamente).</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Cinacalcet a dosis bajas es eficaz en el manejo del HPTS del paciente con ERC no tratado mediante diálisis, al disminuir la iPTH y la calcemia, sin ocasionar efectos adversos graves ni variación significativa de la función renal.</p></span>" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as: Orellana JM, Esteban RJ, Castilla YA, Fernández-Castillo R, Nozal-Fernández G, Esteban MA, et al. Uso de cinacalcet para el control del hiperparatiroidismo en pacientes con diferentes grados de insuficiencia renal. Nefrología. 2016;36:121–125.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1038 "Ancho" => 1650 "Tamanyo" => 93756 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Percent change in eGFR and in bone and mineral metabolism after treatment with cinacalcet between values at baseline and at 12 months. *Represents statistical significance.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col"><span class="elsevierStyleItalic">N</span> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Baseline</th><th class="td" title="table-head " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">6 months</th><th class="td" title="table-head " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">12 months</th><th class="td" title="table-head " align="center" valign="top" scope="col"><span class="elsevierStyleItalic">p</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Mean (SD)</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Median (P25; P75)</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Mean (SD)</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Median (P25; P75)</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Mean (SD)</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Median (P25; P75)</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Creatinine (mg/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(1.30) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.03 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(1.43; 3.57) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(1.52) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.68 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(1.21; 4.25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(1.52) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(1.58; 4.32) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.099 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Urea (mg/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">99.60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(51.10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(59; 133) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">93.67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(51.10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">72.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(59; 133) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">117.83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(57.05) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(75.7; 138.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.117 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PTH (pg/ml) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">392.47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(317.65) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">294 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(176.0; 556) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">293.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(464.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">146 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(110; 253) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">141.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(59.26) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">142.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(98.7; 178.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><span class="elsevierStyleBold">0.009</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Serum calcium (mg/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(0.55) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(10.1; 10.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(1.06) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(8.9; 10.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(1.04) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(8.5; 10.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><span class="elsevierStyleBold">0.005</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Calciuria (mg/24<span class="elsevierStyleHsp" style=""></span>h) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(0.18) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(0.7; 0.17) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(0.21) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(0.10; 0.48) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(0.90) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(0.1; 0.26) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.154 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Serum phosphorus (mg/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(1.06) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(2.95; 4.32) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(0.67) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(2.97; 4.37) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.88 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(0.85) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(3.3; 4.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><span class="elsevierStyleBold">0.011</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Estimated glomerular filtration rate (ml/min/1.73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29.78 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(15.35) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28.81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(14.4; 41.03) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33.44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(24.00) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28.63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(14.9; 48.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31.02 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(17.42) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33.28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(14.3; 44.46) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.807 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Beta-crosslaps (pg/ml) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">884.92 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(797.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">616 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(248; 1309) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1657.67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(1291.71) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1785 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(571; 2109) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1053.63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(999.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">763 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(461; 1129) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><span class="elsevierStyleBold">0.041</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Osteocalcin (ng/ml) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">226.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(460.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(19; 219) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">122.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(91.32) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">140.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(23; 181) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">86.45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(125.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(18; 83) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.919 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total alkaline phosphatase (U/l) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">110.83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(88.21) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">81.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(65.0; 126.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">133.85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(86.67) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">121.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(91; 130.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">78.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(26.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">73.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(54.5; 100.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.833 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">P1NP (ng/ml) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">149.08 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(166.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">99 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(42.5; 207.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">217.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(250.62) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">123.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(55.8; 282) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">126.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(132.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">82.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(46; 171) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.314 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1383009.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Calculated according to the Wilcoxon signed-rank test for baseline and 12 months.</p> <p class="elsevierStyleNotepara" id="npar0010">Bold: statistical significance (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05; PTH, phosphorus, calcium and beta-crosslaps).</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Evolution of estimated glomerular filtration rate and bone and mineral metabolism parameters in patients with secondary hyperparathyroidism due to CKD not treated with dialysis after cinacalce treatment: comparisons at baseline and at 6 and 12 months.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib0075" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evolución de los marcadores óseos durante el tratamiento con cinacalcet en pacientes con hiperparatiroidismo secundario en hemodiálisis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "O. 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| 2024 April | 72 | 34 | 106 |
| 2024 March | 78 | 22 | 100 |
| 2024 February | 70 | 48 | 118 |
| 2024 January | 84 | 25 | 109 |
| 2023 December | 88 | 23 | 111 |
| 2023 November | 116 | 30 | 146 |
| 2023 October | 167 | 30 | 197 |
| 2023 September | 77 | 27 | 104 |
| 2023 August | 103 | 31 | 134 |
| 2023 July | 137 | 27 | 164 |
| 2023 June | 90 | 15 | 105 |
| 2023 May | 95 | 30 | 125 |
| 2023 April | 74 | 19 | 93 |
| 2023 March | 95 | 30 | 125 |
| 2023 February | 84 | 25 | 109 |
| 2023 January | 64 | 30 | 94 |
| 2022 December | 76 | 30 | 106 |
| 2022 November | 59 | 35 | 94 |
| 2022 October | 78 | 40 | 118 |
| 2022 September | 63 | 33 | 96 |
| 2022 August | 67 | 36 | 103 |
| 2022 July | 47 | 47 | 94 |
| 2022 June | 58 | 28 | 86 |
| 2022 May | 54 | 46 | 100 |
| 2022 April | 70 | 42 | 112 |
| 2022 March | 56 | 56 | 112 |
| 2022 February | 50 | 37 | 87 |
| 2022 January | 42 | 41 | 83 |
| 2021 December | 58 | 39 | 97 |
| 2021 November | 54 | 40 | 94 |
| 2021 October | 46 | 31 | 77 |
| 2021 September | 63 | 41 | 104 |
| 2021 August | 45 | 28 | 73 |
| 2021 July | 37 | 35 | 72 |
| 2021 June | 68 | 23 | 91 |
| 2021 May | 81 | 33 | 114 |
| 2021 April | 112 | 58 | 170 |
| 2021 March | 105 | 36 | 141 |
| 2021 February | 102 | 41 | 143 |
| 2021 January | 73 | 34 | 107 |
| 2020 December | 84 | 24 | 108 |
| 2020 November | 77 | 12 | 89 |
| 2020 October | 66 | 31 | 97 |
| 2020 September | 52 | 33 | 85 |
| 2020 August | 92 | 26 | 118 |
| 2020 July | 81 | 25 | 106 |
| 2020 June | 58 | 16 | 74 |
| 2020 May | 62 | 22 | 84 |
| 2020 April | 76 | 29 | 105 |
| 2020 March | 73 | 12 | 85 |
| 2020 February | 90 | 28 | 118 |
| 2020 January | 91 | 32 | 123 |
| 2019 December | 71 | 24 | 95 |
| 2019 November | 78 | 27 | 105 |
| 2019 October | 79 | 17 | 96 |
| 2019 September | 72 | 23 | 95 |
| 2019 August | 62 | 19 | 81 |
| 2019 July | 54 | 25 | 79 |
| 2019 June | 52 | 22 | 74 |
| 2019 May | 34 | 30 | 64 |
| 2019 April | 86 | 34 | 120 |
| 2019 March | 53 | 26 | 79 |
| 2019 February | 63 | 23 | 86 |
| 2019 January | 51 | 22 | 73 |
| 2018 December | 143 | 43 | 186 |
| 2018 November | 162 | 19 | 181 |
| 2018 October | 168 | 16 | 184 |
| 2018 September | 111 | 15 | 126 |
| 2018 August | 72 | 22 | 94 |
| 2018 July | 37 | 14 | 51 |
| 2018 June | 39 | 16 | 55 |
| 2018 May | 36 | 15 | 51 |
| 2018 April | 60 | 16 | 76 |
| 2018 March | 45 | 8 | 53 |
| 2018 February | 51 | 11 | 62 |
| 2018 January | 41 | 7 | 48 |
| 2017 December | 53 | 7 | 60 |
| 2017 November | 53 | 12 | 65 |
| 2017 October | 45 | 8 | 53 |
| 2017 September | 39 | 11 | 50 |
| 2017 August | 30 | 6 | 36 |
| 2017 July | 31 | 6 | 37 |
| 2017 June | 38 | 6 | 44 |
| 2017 May | 41 | 12 | 53 |
| 2017 April | 35 | 10 | 45 |
| 2017 March | 24 | 11 | 35 |
| 2017 February | 29 | 29 | 58 |
| 2017 January | 35 | 16 | 51 |
| 2016 December | 44 | 10 | 54 |
| 2016 November | 63 | 13 | 76 |
| 2016 October | 112 | 13 | 125 |
| 2016 September | 196 | 11 | 207 |
| 2016 August | 221 | 7 | 228 |
| 2016 July | 285 | 12 | 297 |
| 2016 June | 161 | 0 | 161 |
| 2016 May | 77 | 0 | 77 |
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