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    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Presently&#44; it is widely accepted that chronic kidney disease &#40;CKD&#41; is an independent cardiovascular &#40;CV&#41; risk factor and that its mortality rate increases exponentially as kidney function progressively deteriorates&#46;<a class="elsevierStyleCrossRef" href="#bib0755"><span class="elsevierStyleSup">1</span></a> In this context&#44; we have previously described the types of CV calcification&#44;<a class="elsevierStyleCrossRefs" href="#bib0760"><span class="elsevierStyleSup">2&#44;3</span></a> its association with CV events&#44; mortality&#44;<a class="elsevierStyleCrossRef" href="#bib0760"><span class="elsevierStyleSup">2</span></a> and why we justify assessing vascular calcification in routine nephrology clinical practice&#46;<a class="elsevierStyleCrossRef" href="#bib0760"><span class="elsevierStyleSup">2</span></a> Nonetheless&#44; it is important to demonstrate beforehand that CV calcification is also a modifiable risk factor with at least the possibility of decreasing its progression and not aggravating it in the case of not being able to reverse it&#46; Then&#44; the objective of the second part of this review&#44; is to explain how CV calcification is a modifiable risk factor despite being a late and secondary phenomenon and only circumstancial evidence available&#46;<a class="elsevierStyleCrossRefs" href="#bib0770"><span class="elsevierStyleSup">4&#8211;6</span></a> Certainly CV calcification is a risk factor that&#44; unfortunately&#44; we may contribute to by adding unwanted iatrogenic effects&#46;<a class="elsevierStyleCrossRefs" href="#bib0780"><span class="elsevierStyleSup">6&#8211;9</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Controlling traditional cardiovascular risk factors and vascular calcification</span><p id="par0010" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Observational</span> studies have shown that the differential use of drugs acting on the CV system such as statins&#44; &#946;-blockers&#44; calcium channel antagonists&#44; and angiotensin-converting enzyme &#40;ACE&#41; inhibitors&#47;angiotensin-II-receptor blockers &#40;ARB&#41; are associated with a lower risk of CV events and death in CKD patients&#46;<a class="elsevierStyleCrossRef" href="#bib0800"><span class="elsevierStyleSup">10</span></a> However&#44; there is no single drug that clearly demonstrates an improvement in survival in dialysis patients&#46;<a class="elsevierStyleCrossRef" href="#bib0805"><span class="elsevierStyleSup">11</span></a> The treatment of CV risk factors for atherosclerosis&#44; such as hyperlipidaemia&#44; does not improve the survival of these patients&#44;<a class="elsevierStyleCrossRefs" href="#bib0810"><span class="elsevierStyleSup">12&#44;13</span></a> and only the reduction of LDL cholesterol with simvastatin plus ezetimibe decreased the incidence of CV events in a wide range of advanced CKD patients&#44; but without demonstrating a benefit in overall survival&#46;<a class="elsevierStyleCrossRef" href="#bib0820"><span class="elsevierStyleSup">14</span></a> Treating hyperlipidaemia with statins has also failed to reduce vascular calcification&#46;<a class="elsevierStyleCrossRefs" href="#bib0825"><span class="elsevierStyleSup">15&#44;16</span></a> Only one recent meta-analysis has indicated that using statins is effective in the primary prevention of CV disease in CKD&#46;<a class="elsevierStyleCrossRef" href="#bib0835"><span class="elsevierStyleSup">17</span></a> Moreover&#44; there are very limited or non-existent data available on the effect of control of diabetes and blood pressure&#44; as well as quitting tobacco on vascular calcification or the CV risk in the CKD population&#46;<a class="elsevierStyleCrossRef" href="#bib0840"><span class="elsevierStyleSup">18</span></a> Only in new experimental models&#44; ARBs have been demonstrated to have powerful protective effects on vascular calcification by interrupting vascular osteogenesis&#46; The combination of statins and ARBs produces potent synergistic protective effects against vascular calcification in CKD that is beyond the control of blood pressure&#46;<a class="elsevierStyleCrossRefs" href="#bib0845"><span class="elsevierStyleSup">19&#8211;22</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Control of CKD&#8211;MBD and vascular calcification-related risk factors</span><p id="par0015" class="elsevierStylePara elsevierViewall">Many CKD&#8211;MBD-related treatments&#44; such as phosphate &#40;P&#41; binders&#44; vitamin D derivatives&#44; calcimimetics&#44; and others&#44; have been widely demonstrated to influence on <span class="elsevierStyleItalic">experimental</span> vascular calcification and point to the possibility of being able to modify its <span class="elsevierStyleItalic">clinical</span> progression&#44; including dialysis patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0785"><span class="elsevierStyleSup">7&#44;23&#8211;26</span></a> Nevertheless&#44; it should be recognised that there is no definitive proof in any randomised clinical study showing that a single drug in this therapeutic area has an irrefutable impact on major events in CKD patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0790"><span class="elsevierStyleSup">8&#44;9</span></a></p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Recent information about phosphate binders</span><p id="par0020" class="elsevierStylePara elsevierViewall">Hyperphosphataemia is recognised as an independent CV risk factor&#46; Abnormal P metabolism occurs early in CKD and there is a general consensus that it is one of the most important factors contributing in the onset of CV calcification&#44; along with changes in intra- and extracellular Ca content&#46; Both have a strong influence on the vascular smooth muscle cell &#40;VSMC&#41; function&#46;<a class="elsevierStyleCrossRefs" href="#bib0885"><span class="elsevierStyleSup">27&#44;28</span></a> Since the experiments by Jono et al&#46;<a class="elsevierStyleCrossRef" href="#bib0885"><span class="elsevierStyleSup">27</span></a> and Giachelli et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0895"><span class="elsevierStyleSup">29</span></a> nephrologists have recognised the need to avoid P overload&#44; not only as a promoter of secondary hyperparathyroidism&#44; but also because of its direct effects on CV health&#44;<a class="elsevierStyleCrossRefs" href="#bib0900"><span class="elsevierStyleSup">30&#8211;32</span></a> including its potent proinflammatory and oxidative effects<a class="elsevierStyleCrossRefs" href="#bib0915"><span class="elsevierStyleSup">33&#44;34</span></a> that may affect even patients with mild CKD and possibly the general population&#46;<a class="elsevierStyleCrossRef" href="#bib0925"><span class="elsevierStyleSup">35</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Goodman et al&#46;&#8217;s initial publication in adolescents on dialysis&#44; showed that they already had vascular calcifications and that the amount of Ca they ingested was double than those without calcifications&#46; This information started a broad debate about the different binders &#40;calcium vs&#46; non-calcium&#41; that has not been fully resolved yet&#46;<a class="elsevierStyleCrossRefs" href="#bib0930"><span class="elsevierStyleSup">36&#8211;38</span></a> Several randomised studies conducted in adults on dialysis have demonstrated that CV calcification progression was truly modifiable by choosing non-calcium P binders&#46;<a class="elsevierStyleCrossRefs" href="#bib0785"><span class="elsevierStyleSup">7&#44;39&#8211;42</span></a> However these results are not consistent&#46;<a class="elsevierStyleCrossRef" href="#bib0965"><span class="elsevierStyleSup">43</span></a> In some clinical trials&#44; negative results have been attributed to a patient population that had a higher number of CV risk factors&#59;<a class="elsevierStyleCrossRefs" href="#bib0970"><span class="elsevierStyleSup">44&#44;45</span></a> other studies faced obstacles such as a small sample size or the use of high Ca concentrations in the dialysate bath in many patients&#46;<a class="elsevierStyleCrossRef" href="#bib0980"><span class="elsevierStyleSup">46</span></a> Therefore&#44; despite the fact that the &#8220;Dialysis Clinical Outcomes Revisited&#8221; &#40;DCOR&#41; study found that using sevelamer HCl in dialysis patients did not significantly improve the mortality rates&#44;<a class="elsevierStyleCrossRefs" href="#bib0985"><span class="elsevierStyleSup">47&#44;48</span></a> the 2009 KDIGO guidelines proposed a restriction of Ca-based P-binder dose in the presence of arterial calcification &#40;guideline 4&#46;1&#46;5&#59; 2C&#41;&#44; at least until more conclusive studies are conducted&#46;<a class="elsevierStyleCrossRef" href="#bib0900"><span class="elsevierStyleSup">30</span></a> This represents a step forward in comparison to the previous American guidelines<a class="elsevierStyleCrossRef" href="#bib0995"><span class="elsevierStyleSup">49</span></a> &#40;K-DOQI 2003&#41; where&#44; curiously&#44; the Ca-based P binders were limited only to cases with <span class="elsevierStyleItalic">severe</span> vascular calcification &#40;a situation that may be too advanced to modify the harmful consequences&#41;&#46; Although the DCOR study did not strictly demonstrate the superiority of sevelamer versus calcium-based binders&#44; it cannot be said that Ca-based P binders are safe&#46;<a class="elsevierStyleCrossRefs" href="#bib0910"><span class="elsevierStyleSup">32&#44;50</span></a> With need to take into consideration also economic aspects&#44;<a class="elsevierStyleCrossRef" href="#bib1005"><span class="elsevierStyleSup">51</span></a> at least these studies have made the nephrology community aware that indiscriminately using calcium-based binders may be inappropriate and that it might be safer to limit Ca intake to less than 1<span class="elsevierStyleHsp" style=""></span>g&#47;day in CKD patients&#46;<a class="elsevierStyleCrossRef" href="#bib1010"><span class="elsevierStyleSup">52</span></a> A recent metabolic study demonstrated that even in stage 3b-4 CKD patients &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&#59; mean GFR 36<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#59; mean P<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#46;8<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; administering 1&#46;5<span class="elsevierStyleHsp" style=""></span>g of calcium carbonate converted a neutral Ca balance into a largely positive balance&#44;<a class="elsevierStyleCrossRef" href="#bib1015"><span class="elsevierStyleSup">53</span></a> although it is unknown whether this altered balance is temporal&#44; by inducing adaptation phenomena&#44; or whether this excess of Ca ends up being deposited in extraosseous tissues&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">More recent studies in dialysis patients have shown that the progression of vascular calcification was attenuated not only by sevelamer but also bylanthanum and&#44; in two small pilot studies&#44; by the use of P binders containing magnesium&#46;<a class="elsevierStyleCrossRefs" href="#bib1020"><span class="elsevierStyleSup">54&#8211;59</span></a> A recent meta-analysis has also reinforced the idea that it may be possible to attenuate the progression of vascular calcification with non-calcium P binders&#46;<a class="elsevierStyleCrossRef" href="#bib1050"><span class="elsevierStyleSup">60</span></a> Moreover&#44; in another randomised&#44; open-label&#44; parallel groups study including 466 Italian patients who were starting haemodialysis&#44; sevelamer improved <span class="elsevierStyleItalic">survival</span> as compared with calcium-based P binders&#44;<a class="elsevierStyleCrossRef" href="#bib1055"><span class="elsevierStyleSup">61</span></a> although it could not be established a direct relationship between the Ca load and worse outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib1055"><span class="elsevierStyleSup">61</span></a> Furthermore&#44; in another recent meta-analysis&#44; non-calcium P binders were associated with a criticised reduction of overall mortality risk &#40;22&#37;&#41; in CKD patients &#40;mostly dialysis patients treated with sevelamer&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0770"><span class="elsevierStyleSup">4</span></a> in contrast to the negative results from other previous meta-analyses&#46;<a class="elsevierStyleCrossRefs" href="#bib0935"><span class="elsevierStyleSup">37&#44;62</span></a> Nonetheless&#44; in some of these studies high doses of binders were administered to achieve protocol objectives&#59; therefore&#44; these results should be extrapolated with caution to those situations in which moderate doses of Ca-based binders are used or those cases in which both types of binders &#40;with and without Ca&#41; are being administered&#46;<a class="elsevierStyleCrossRefs" href="#bib1065"><span class="elsevierStyleSup">63&#44;64</span></a> Another study found that normal individuals and patients with stage 3b-4 CKD had a slightly negative or neutral Ca balance while eating a 800<span class="elsevierStyleHsp" style=""></span>mg&#47;day Ca diet&#44; however with a 2000<span class="elsevierStyleHsp" style=""></span>mg&#47;day diet&#44; the normal individuals had a slightly positive balance and the CKD patients had a clearly positive balance&#44; at least during the 9 days of the study&#46;<a class="elsevierStyleCrossRef" href="#bib1075"><span class="elsevierStyleSup">65</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Lastly&#44; a randomised&#44; multi-centre&#44; open-label pilot study conducted in 212 outpatients with stage 3&#8211;4 CKD recruited over a maximum of 36 months demonstrated that treatment with sevelamer to maintain plasma P within the normal range&#44; was associated with a significantly lower incidence of de novo CAC among patients with no baseline CV disease &#40;12&#46;8&#37; vs&#46; 81&#46;8&#37; for sevelamer and Ca carbonate&#44; respectively&#41;&#44; as well as slower CAC progression among the patients with evidence of CAC at the start of the study&#46;<a class="elsevierStyleCrossRef" href="#bib1080"><span class="elsevierStyleSup">66</span></a> A significant <span class="elsevierStyleItalic">regression</span> of CAC was also detected in 24 patients treated with sevelamer&#44; and only in 2 patients treated with Ca&#46; The overall mortality and the final composite endpoint of death and dialysis inception were lower in the patients assigned to sevelamer&#46;<a class="elsevierStyleCrossRef" href="#bib1080"><span class="elsevierStyleSup">66</span></a> This study did not include a placebo arm and included patients with moderate hyperphosphataemia &#40;4&#46;84<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;3<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41;&#46; Conversely&#44; in another&#44; smaller randomised study of 148 patients with moderate CKD &#40;GFR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>20&#8211;45<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> with a mean P of 4&#46;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; comparison of Ca phosphate binders&#44; sevelamer&#44; and lanthanum vs&#46; placebo showed a completely unexpected increase in vascular calcification in all groups&#44; even though in the post hoc analysis&#44; the degree of progression was higher in the Ca arm&#46;<a class="elsevierStyleCrossRef" href="#bib1085"><span class="elsevierStyleSup">67</span></a> In another study&#44;<a class="elsevierStyleCrossRef" href="#bib1090"><span class="elsevierStyleSup">68</span></a> rosuvastatin and sevelamer did not delay the progression of vascular calcification in CKD patients not yet in dialysis&#46; Therefore&#44; despite the demonstrated potential benefit for survival&#44; at least in some CKD patients&#44; additional studies are needed to define the effects of P binders in CKD patients before starting dialysis&#46; In fact&#44; this is one of the areas of nephrology in which we have less evidence and limited alternatives&#46; A large controversy has been generated on whether P binders should be prescribed in stage 3&#8211;4 CKD&#44;<a class="elsevierStyleCrossRefs" href="#bib1095"><span class="elsevierStyleSup">69&#8211;71</span></a> this controversy illustrate the extreme necessity to conduct prospective clinical studies measuring hard events&#46;<a class="elsevierStyleCrossRefs" href="#bib1095"><span class="elsevierStyleSup">69&#8211;71</span></a> According to the prescribing information&#44; P binders without Ca should be restricted to CKD patients not in dialysis if serum P is greater than 1&#46;78<span class="elsevierStyleHsp" style=""></span>mmol&#47;l &#40;5&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41;&#46; Nevertheless&#44; it should be noted that in the recent controversies on the KDIGO guidelines&#44;<a class="elsevierStyleCrossRef" href="#bib1065"><span class="elsevierStyleSup">63</span></a> the concern about Ca overload as a risk factor for progression of vascular calcification in CKD was clearly emphasised&#46;<a class="elsevierStyleCrossRefs" href="#bib0935"><span class="elsevierStyleSup">37&#44;66&#44;67&#44;72&#44;73</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Controlling secondary hyperparathyroidism with calcimimetics</span><p id="par0040" class="elsevierStylePara elsevierViewall">In addition to the experimental data showing a neutral or protective effect of calcimimetics on uraemic <span class="elsevierStyleItalic">atherosclerosis</span> or vascular calcification&#44;<a class="elsevierStyleCrossRefs" href="#bib0870"><span class="elsevierStyleSup">24&#44;74&#44;75</span></a> a randomised clinical trial recently demonstrated that cinacalcet&#44; along with low-doses of vitamin D analogues&#44; can attenuate the progression of vascular calcification in dialysis patients versus the standard treatment &#40;different doses of vitamin D analogues or binders&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0875"><span class="elsevierStyleSup">25</span></a> Although the study did not clearly demonstrate a significant benefit &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;07&#41;&#44; there was a clear tendency towards decreased progression of CAC&#44; thoracic aorta calcification&#44; and cardiac valve calcification in the group treated with calcimimetics&#46; This effect was especially significant in those patients adhering to the initially designed protocol maintaining a low dose of vitamin D analogues&#46;<a class="elsevierStyleCrossRef" href="#bib0880"><span class="elsevierStyleSup">26</span></a> Similar results were described in an observational study conducted in Japan&#46;<a class="elsevierStyleCrossRef" href="#bib1130"><span class="elsevierStyleSup">76</span></a> Furthermore&#44; another retrospective study including dialysis patients on intravenous vitamin D therapy &#40;a surrogate marker for secondary hyperparathyroidism&#41;&#44; the prescription of calcimimetics was associated with a significant improvement in survival&#46;<a class="elsevierStyleCrossRef" href="#bib1135"><span class="elsevierStyleSup">77</span></a> However&#44; the EVOLVE study&#44;<a class="elsevierStyleCrossRef" href="#bib1140"><span class="elsevierStyleSup">78</span></a> comparing calcimimetics vs&#46; standard therapy in the largest study conducted in haemodialysis patients &#40;3883&#41;&#44; showed that cinacalcet did <span class="elsevierStyleItalic">not</span> significantly reduce the risk of death or CV events in dialysis patients with moderate to severe secondary hyperparathyroidism after an <span class="elsevierStyleItalic">unadjusted</span> intention-to-treat statistical analysis&#46; Similarly&#44; in a recent meta-analysis&#44; based essentially on the above study&#44; calcimimetics did not seem to improve CV or overall mortality&#46;<a class="elsevierStyleCrossRef" href="#bib1145"><span class="elsevierStyleSup">79</span></a> As a result&#44; as previously observed with sevelamer in the DCOR study&#44;<a class="elsevierStyleCrossRefs" href="#bib0985"><span class="elsevierStyleSup">47&#44;48</span></a> it was not possible to definitively establish a direct relation between therapeutic measures that potentially attenuate vascular calcification progression in dialysis patients and benefits for survival&#46; However&#44; it is important to note that&#44; in addition to other <span class="elsevierStyleItalic">nominally</span> significant beneficial effects associated with sevelamer and cinacalcet&#44;<a class="elsevierStyleCrossRefs" href="#bib0985"><span class="elsevierStyleSup">47&#44;48&#44;78</span></a> it was observed in both studies that age had a highly significant interaction on the treatment effect&#46; Both drugs significantly reduced mortality in a <span class="elsevierStyleItalic">predefined</span> subgroup of patients over 65 years of age&#59; this result is likely due to the higher statistical power inherent to a higher number of CV events and mortality in this age group&#46;<a class="elsevierStyleCrossRefs" href="#bib1140"><span class="elsevierStyleSup">78&#44;80</span></a> A similar interaction with age was observed with lanthanum carbonate&#46;<a class="elsevierStyleCrossRef" href="#bib1155"><span class="elsevierStyleSup">81</span></a> In addition&#44; in the general population a significant association between vascular calcification and kidney function has also been recently described in the elderly&#44; but not in younger individuals&#46;<a class="elsevierStyleCrossRef" href="#bib1160"><span class="elsevierStyleSup">82</span></a> It is important to note that&#44; in the case of the EVOLVE study&#44; cinacalcet <span class="elsevierStyleItalic">did</span> significantly reduce the risk of death or major CV events in dialysis patients in a second predefined intention-to-treat analysis when <span class="elsevierStyleItalic">adjusted</span> for age or other factors&#44; as well as other complex sensitivity analyses&#44; despite the excessive number of <span class="elsevierStyleItalic">drop-ins</span> and <span class="elsevierStyleItalic">drop-outs&#46;</span><a class="elsevierStyleCrossRefs" href="#bib1140"><span class="elsevierStyleSup">78&#44;83</span></a> Various beneficial effects of cinacalcet have also been described in post hoc studies&#44;<a class="elsevierStyleCrossRefs" href="#bib1165"><span class="elsevierStyleSup">83&#8211;88</span></a> including decreased mortality in non-atherosclerotic events &#40;including sudden death and heart failure&#41; in patients treated with cinacalcet&#46;<a class="elsevierStyleCrossRef" href="#bib1180"><span class="elsevierStyleSup">86</span></a> We therefore believe that the EVOLVE study should not be considered a <span class="elsevierStyleItalic">negative</span> study&#44; but rather an inconclusive&#44; non-definitive study&#44; since the absence of evidence cannot in any way be considered evidence of absence&#46;<a class="elsevierStyleCrossRefs" href="#bib1000"><span class="elsevierStyleSup">50&#44;83</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Lastly&#44; it is important to emphasise that calcimimetics have also been successfully used to treat some cases of calciphylaxis&#46;<a class="elsevierStyleCrossRefs" href="#bib1185"><span class="elsevierStyleSup">87&#44;89</span></a> Calciphylaxis episodes occurred significantly less often in the group of patients treated with cinacalcet in the EVOLVE study and in a post hoc analysis&#46;<a class="elsevierStyleCrossRefs" href="#bib1140"><span class="elsevierStyleSup">78&#44;87</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Calcidiol and vitamin D receptor activators</span><p id="par0050" class="elsevierStylePara elsevierViewall">Low levels of calcidiol &#40;25-OH vitamin D&#41; have been directly associated with the presence and progression of vascular calcification and represent a new CV risk marker on their own&#46;<a class="elsevierStyleCrossRefs" href="#bib1200"><span class="elsevierStyleSup">90&#44;91</span></a> Although it may only be a mere bystander maintaining &#8220;normal&#8221; levels seems to be desirable&#46; Spanish guidelines<a class="elsevierStyleCrossRef" href="#bib1210"><span class="elsevierStyleSup">92</span></a> recommended to maintain normal levels of calcidiol to reduce vascular calcification progression&#44; maintain a normal bone turnover&#44;<a class="elsevierStyleCrossRefs" href="#bib0780"><span class="elsevierStyleSup">6&#44;91</span></a> and provide the other pleiotropic effects described for vitamin D&#44; including vascular regeneration&#44; anti-inflammatory effects&#44; and anti-renin activity&#44; among others&#46;<a class="elsevierStyleCrossRefs" href="#bib1215"><span class="elsevierStyleSup">93&#8211;96</span></a> However&#44; there are no <span class="elsevierStyleItalic">prospective</span>&#44; randomised clinical trials that have assessed the impact of <span class="elsevierStyleItalic">native</span> vitamin D or vitamin D receptor &#40;VDR&#41; activators such as calcitriol&#44; alfacalcidol&#44; paricalcitol&#44; or others on human vascular calcification&#46; Experimental studies have demonstrated differential effects between calcitriol and other VDR activators on extraosseous calcification&#46; Calcitriol is a classic&#44; direct&#44; dose-dependent inducer of <span class="elsevierStyleItalic">experimental</span> vascular calcification&#44; especially in the presence of high P exposure or as the result of systemic vitamin D-induced Ca and P accumulation&#44; more than a local effect on the artery wall&#46;<a class="elsevierStyleCrossRefs" href="#bib0870"><span class="elsevierStyleSup">24&#44;74&#44;97</span></a> Furthermore&#44; the lowest doses of both calcitriol and paricalcitol seem to protect against vascular calcification&#44; likely through klotho restoration and osteopontin expression&#46;<a class="elsevierStyleCrossRefs" href="#bib1240"><span class="elsevierStyleSup">98&#8211;100</span></a> Therefore&#44; the presence of a bimodal effect of the VDR activators regarding vascular calcification regulation can be postulated&#46; In general&#44; experimental data supporting lower toxicity with some VDR activators versus calcitriol are not consistent between studies&#44; but they seem to support the assertion that there is reduced calcification induction with other selective VDR activators such as paricalcitol&#46;<a class="elsevierStyleCrossRefs" href="#bib0870"><span class="elsevierStyleSup">24&#44;74&#44;95&#44;101</span></a> For example&#44; paricalcitol&#44; in contrast to calcitriol&#44; decreases Wnt&#47;&#946;-catenin pathway activation&#44; the most important signalling pathway in transdifferentiating VSMC into osteoblasts&#46;<a class="elsevierStyleCrossRef" href="#bib1260"><span class="elsevierStyleSup">102</span></a> Paricalcitol may also have an effect on earlier stages of vascular disease&#59; it is unknown whether this is true of other VDR activators&#46;<a class="elsevierStyleCrossRef" href="#bib1265"><span class="elsevierStyleSup">103</span></a> Furthermore&#44; several <span class="elsevierStyleItalic">retrospective</span> studies have described a consistent and solid benefit on survival for haemodialysis patients with <span class="elsevierStyleItalic">selective</span> VDR activators<a class="elsevierStyleCrossRefs" href="#bib1270"><span class="elsevierStyleSup">104&#44;105</span></a> and&#44; although it has been questioned&#44;<a class="elsevierStyleCrossRef" href="#bib1280"><span class="elsevierStyleSup">106</span></a> the benefit seems to be more pronounced in the low-dose range and among patients who received selective VDR activators&#46;<a class="elsevierStyleCrossRefs" href="#bib0840"><span class="elsevierStyleSup">18&#44;104</span></a> Lastly&#44; a recent meta-analysis including 14 observational studies &#40;194&#44;932 patients&#41; showed that VDR activator therapies are associated with a lower mortality in CKD patients&#44;<a class="elsevierStyleCrossRef" href="#bib1285"><span class="elsevierStyleSup">107</span></a> although there is no consistency between the different meta-analyses&#46;<a class="elsevierStyleCrossRef" href="#bib1290"><span class="elsevierStyleSup">108</span></a> To date there is no published prospective clinical trial assessing the effect of VDR activators on survival so the previous potential beneficial results could be confirmed&#44; although by no means this beneficial effect should be rejected either&#46;<a class="elsevierStyleCrossRef" href="#bib1295"><span class="elsevierStyleSup">109</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Vitamin K</span><p id="par0055" class="elsevierStylePara elsevierViewall">Vitamin K is necessary as a cofactor in the process of converting inactive decarboxylated extracellular matrix proteins into active carboxylated proteins&#46; Osteocalcin and Matrix Gla protein &#40;MGP&#41; require the presence of vitamin K for activation and warfarin&#44; as a vitamin K antagonist&#44; inhibits coagulation&#44; but long-term use can promote vascular calcification and overregulation of decarboxylated MGP&#46;<a class="elsevierStyleCrossRefs" href="#bib1300"><span class="elsevierStyleSup">110&#44;111</span></a> The association between CAC and vitamin K antagonist therapy was already known in patients with low-risk atrial fibrillation<a class="elsevierStyleCrossRef" href="#bib1310"><span class="elsevierStyleSup">112</span></a> and&#44; recently&#44; G&#243;rriz et al&#46; confirmed the independent association between the use of oral anticoagulants and vascular calcification&#44; even in CKD patients not on dialysis&#46;<a class="elsevierStyleCrossRef" href="#bib1315"><span class="elsevierStyleSup">113</span></a> Experimental work shows that vitamin K is able to revert warfarin-induced medial calcinosis of elastin<a class="elsevierStyleCrossRef" href="#bib1320"><span class="elsevierStyleSup">114</span></a> and&#44; since vitamin K deficiency is common in dialysis&#44; it is not surprising to see that currently there are several prospective clinical trials evaluating the effect of vitamin K supplementation on CAC progression in CKD and haemodialysis patients&#46;<a class="elsevierStyleCrossRef" href="#bib1325"><span class="elsevierStyleSup">115</span></a> It is possible that the new oral anticoagulants&#44; now available for patients with atrial fibrillation or acute coronary syndrome&#44; may become a therapeutic alternative&#46;<a class="elsevierStyleCrossRefs" href="#bib1330"><span class="elsevierStyleSup">116&#44;117</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Preliminary data on bisphosphonates&#44; thiosulfate&#44; and phytates</span><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Bisphosphonates</span> have also been successfully used &#8220;off label&#8221; to treat calciphylaxis&#46;<a class="elsevierStyleCrossRef" href="#bib1340"><span class="elsevierStyleSup">118</span></a> In addition to the experimental data showing that treatment with pamidronate or etidronate prevents vascular calcification&#44;<a class="elsevierStyleCrossRef" href="#bib1345"><span class="elsevierStyleSup">119</span></a> oral or parenteral etidronate can delay CAC progression and aortic valve calcification&#44; although not all new-generation of bisphosphonates have been shown to reduce calcifications&#46;<a class="elsevierStyleCrossRefs" href="#bib1350"><span class="elsevierStyleSup">120&#8211;123</span></a> In this line&#44; it is worth to mention that the vessel wall possesses a &#8220;natural form of bisphosphonates&#8221;&#44; pyrophosphates&#44; which antagonise alkaline phosphatase and are one of the most effective anticalcifying factors of the vascular wall&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">A randomised clinical trial including 108 hypercholesterolaemic patients revealed that combination therapy with atorvastatin plus etidronate for 12 months significantly reduced atheroma plaques in thoracic and abdominal aorta&#46;<a class="elsevierStyleCrossRef" href="#bib1370"><span class="elsevierStyleSup">124</span></a> Since the vascular effects of bisphosphonates cannot be separated from adequate bone formation&#44; the administration to CKD patients may promote the development or aggravation of adynamic bone disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0900"><span class="elsevierStyleSup">30&#44;125&#44;126</span></a> As a result&#44; a bone biopsy is recommended before using bisphosphonates in patients with a GFR<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> unless a <span class="elsevierStyleItalic">high</span>-turnover bone disease is undeniably present&#44;<a class="elsevierStyleCrossRef" href="#bib0900"><span class="elsevierStyleSup">30</span></a> or in the context of a potentially fatal disease such as calciphylaxis&#46;<a class="elsevierStyleCrossRef" href="#bib1340"><span class="elsevierStyleSup">118</span></a> A similar strategy should likely be applied to new therapies such as denosumab and romosozumab&#44; although the half-life of these drugs in bone is certainly lower&#46;<a class="elsevierStyleCrossRef" href="#bib1385"><span class="elsevierStyleSup">127</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Sodium thiosulfate</span> has been introduced into the therapeutic arsenal against calciphylaxis&#46;<a class="elsevierStyleCrossRef" href="#bib1390"><span class="elsevierStyleSup">128</span></a> It may also attenuate the CAC progression rate versus the non-treatment group&#44; but with a significant decrease in hip bone mineral density&#46;<a class="elsevierStyleCrossRefs" href="#bib1395"><span class="elsevierStyleSup">129&#44;130</span></a> Sodium thiosulfate and other binding agents have been demonstrated to be potentially useful in reversing vessel medial calcification&#44;<a class="elsevierStyleCrossRef" href="#bib1405"><span class="elsevierStyleSup">131</span></a> however the mechanism by which sodium thiosulfate reduces calcification is not fully understood&#46;<a class="elsevierStyleCrossRefs" href="#bib1395"><span class="elsevierStyleSup">129&#44;132</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Given the importance of this topic&#44; new drugs are being developed that could act as vascular calcification inhibitors such as <span class="elsevierStyleItalic">SNF472</span>&#44;<a class="elsevierStyleCrossRef" href="#bib1415"><span class="elsevierStyleSup">133</span></a> an intravenous formulation of myoinositol hexaphosphate &#40;phytate&#41; that prevents hydroxyapatite crystals from forming and growing&#46;<a class="elsevierStyleCrossRefs" href="#bib1420"><span class="elsevierStyleSup">134&#44;135</span></a> It also acts as a calcification antagonist that could be effective as a therapy for treating CV calcification in CKD patients and in calciphylaxis&#46;<a class="elsevierStyleCrossRef" href="#bib1415"><span class="elsevierStyleSup">133</span></a> SNF472 acts through a physicochemical mechanism&#44; binding to the forming or growing crystal&#46;<a class="elsevierStyleCrossRef" href="#bib1430"><span class="elsevierStyleSup">136</span></a> Its high efficacy in animal models and short half-life give it a suitable safety and efficacy profile in CKD&#44; but this will have to be confirmed in long-term clinical studies&#46; At this time it is in phase 1b&#47;2 development&#46;<a class="elsevierStyleCrossRef" href="#bib1430"><span class="elsevierStyleSup">136</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Other possible treatments</span><p id="par0080" class="elsevierStylePara elsevierViewall">There are no studies investigating the effects of <span class="elsevierStyleItalic">parathyroidectomy</span> on the progression or regression of vascular calcification that meet the pre-established inclusion criteria for the 2009 KDIGO guidelines revision&#46; Similarly&#44; to date there are no new data available beyond the classic indication for parathyroidectomy in the form of calciphylaxis associated with severe secondary hyperparathyroidism&#46; In <span class="elsevierStyleItalic">kidney transplantation</span>&#44; few studies have been able to demonstrate stabilisation or attenuation&#44; but do not completely stop&#44; the rate of progression of vascular calcification&#44; despite the significant improvement in kidney function and mineral metabolism parameters&#46;<a class="elsevierStyleCrossRefs" href="#bib1435"><span class="elsevierStyleSup">137&#8211;140</span></a> However&#44; many other CV risk factors&#44; either prior to or within the context of transplantation&#44; may play an additional role in this specific population&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">General recommendations</span><p id="par0085" class="elsevierStylePara elsevierViewall">There are no studies demonstrating that the presence&#47;absence&#47;degree of vascular calcification is associated with changes in the prognosis of CKD patients&#59; however&#44; in this second part of the review we have discussed the extensive evidence&#44; especially in dialysis patients&#44; that some of the treatments used for CKD&#8211;MBD may enhance vascular calcification progression&#44; at least when the calcifications are already present&#46;<a class="elsevierStyleCrossRefs" href="#bib0785"><span class="elsevierStyleSup">7&#44;25</span></a> It is known that vascular calcification is a late&#44; and likely secondary&#44; phenomenon&#44; preceded by inflammation&#44; among other factors&#44; that could be primarily treated by preventing CV disease at earlier stages&#46;<a class="elsevierStyleCrossRef" href="#bib0770"><span class="elsevierStyleSup">4</span></a> However&#44; given the lack of proven strategies for early prevention&#44; along with the serious possibility of inducing iatrogenic effects&#44; makes us believe that a nihilistic attitude towards vascular calcification is not appropriate&#44; considering it as an impossibility to treat&#44; since it has been demonstrated that we can both attenuate its progression or even turn it worse&#46;<a class="elsevierStyleCrossRefs" href="#bib0775"><span class="elsevierStyleSup">5&#44;7&#8211;9&#44;25&#44;50</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Awaiting the difficult viability of a randomised&#44; multi-interventionist clinical trial independent from drug industry&#44; we recognise that CV calcification does not meet the requirements to recommend general screening&#46;<a class="elsevierStyleCrossRefs" href="#bib1455"><span class="elsevierStyleSup">141&#44;142</span></a> However&#44; given the predictive capability of CV calcification and its <span class="elsevierStyleItalic">progression</span>&#44; we believe that CKD patients with vascular calcification would not only require more continuous CV follow-up and monitoring &#40;not only for their calcification&#41;&#44; but would likely benefit from additional initiatives to control the traditional and non-traditional CV risk factors&#46;<a class="elsevierStyleCrossRefs" href="#bib0780"><span class="elsevierStyleSup">6&#44;143</span></a> Among these initiatives we should include more intensive control of plasma P&#44; avoid P overload&#44; administration of fewer treatments or high doses of drugs that could promote CV calcification&#44; which may result in increasing the value of certain treatments above their absolute cost&#46;<a class="elsevierStyleCrossRefs" href="#bib0785"><span class="elsevierStyleSup">7&#44;37&#44;78&#44;83&#44;95&#44;144</span></a> The recent arrival of some generics will undoubtedly help to reduce certain economic burdens while waiting for new evidence&#46;<a class="elsevierStyleCrossRefs" href="#bib0790"><span class="elsevierStyleSup">8&#44;9</span></a> Knowing the presence&#47;absence&#47;degree of CV calcification would improve the individual CV risk assessment&#44; and would help to choose the safest treatment option to avoid the risk of increasing the burden and progression of CV calcification&#59; always considering the high risk of CKD patients and the indirect economic consequences&#46;<a class="elsevierStyleCrossRef" href="#bib0780"><span class="elsevierStyleSup">6</span></a> CV calcification should be assessed in all patients or only in selected cases depending on the resources available in each country&#46;<a class="elsevierStyleCrossRef" href="#bib0780"><span class="elsevierStyleSup">6</span></a> Obviously&#44; the arrival of much less expensive generic drugs could make it easier to use drugs with a better therapeutic margin without the need of strict prescreening&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Different studies have shown consistently that once vascular calcification is established it follows a progressive&#44; and likely accelerated&#44; course&#46;<a class="elsevierStyleCrossRef" href="#bib1475"><span class="elsevierStyleSup">145</span></a> Therefore from a purely academic perspective&#44; it is clear that the use of non-Ca-based P binders should be encouraged&#44; especially in patients who already have vascular calcifications and in those with low levels of PTH or alkaline phosphatase&#46; Patients with specific characteristics may also benefit from non-Ca-based P binders&#44; e&#46;g&#46; over 65 years with a reasonable life expectancy&#44;<a class="elsevierStyleCrossRefs" href="#bib0985"><span class="elsevierStyleSup">47&#44;81</span></a> diabetics&#44; treated with warfarin&#44; incident dialysis patients in whom it is anticipated a long time on the transplant waiting list&#44; young CKD patients in whom a long evolution is expected&#44; or patients with proven progression of vascular calcification&#46; Magnesium and iron deficiency should probably be avoided as well&#44; especially in these patients&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Some patients with moderate&#8211;severe secondary hyperparathyroidism should be preferentially treated with calcimimetics or low-dose VDR activators&#46;<a class="elsevierStyleCrossRefs" href="#bib0875"><span class="elsevierStyleSup">25&#44;78</span></a><span class="elsevierStyleItalic">Native</span> vitamin D or selective VDR activators could be preferentially considered in patients with vascular calcification with low serum calcium without hyperphosphataemia&#44; and native vitamin D in patients with suspected adynamic bone disease<a class="elsevierStyleCrossRefs" href="#bib1210"><span class="elsevierStyleSup">92&#44;146</span></a>&#59; in addition&#44; exposure to high Ca concentrations in the dialysate bath should be limited&#44;<a class="elsevierStyleCrossRefs" href="#bib1375"><span class="elsevierStyleSup">125&#44;147&#8211;149</span></a> including peritoneal dialysis patients&#46;<a class="elsevierStyleCrossRef" href="#bib1500"><span class="elsevierStyleSup">150</span></a> In any case&#44; the KDIGO guidelines propose an assessment of vascular calcification in <span class="elsevierStyleItalic">any</span> patient in whom awareness of its presence could influence therapeutic decision&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">As we have shown in the first part of this review&#44; we consider that initial assessment of vascular calcification should be done with unsophisticated plain X-rays&#44; and we believe that the presence of vascular calcification&#44; especially in muscular arteries such as hands arteries&#44; would emphasise the need to control Ca&#8211;P metabolism-related factors &#40;and each nephrology community would need to establish an Adragao score interval where the most expensive treatments should be implemented depending on the different finantial resources&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Finally&#44; it is known that patients who do <span class="elsevierStyleItalic">not</span> present valve or vascular calcification have a good prognosis during the following years and it is likely that the future of these patients will not be in danger if more economical medications are used&#44; should that priority be above academic considerations&#46; Nevertheless&#44; it is obvious that studies aimed to confirm these ideas&#44; as well as the recommendations related to the imaging technique used and re-analysis periodicity&#44; especially in young patients who are not candidates for kidney transplant within a reasonable period of time&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conclusions</span><p id="par0115" class="elsevierStylePara elsevierViewall">CKD patients present a very high risk of CV disease and premature death&#59; therefore we should offer them the opportunity to have the best prevention and treatment possible&#46; Unfortunately&#44; though the absolute costs are a concern&#44; quantitative or qualitative knowledge of CV calcification could help to optimise economic resources and to assign the more expensive treatments to the patients with greater expectations of improvement&#46; Therefore&#44; we believe that CV calcification should be part of future protocols and clinical studies since it is a distinguishing characteristic of CKD&#8211;MBD&#44; it is a valid predictor of clinical evolution&#44; it is modifiable&#44; and its progression seems to increase with certain treatments &#40;iatrogenic effect&#41; whereas others strategies seem to attenuate it&#46; Obviously&#44; assessing vascular calcification only makes sense if the result can be used by the nephrologist to make treatment decisions&#44; especially early decisions&#44; especially early in the course of the disease&#44; and with the possibility of following the Hippocratic principle of &#8220;first&#44; do no harm&#8221; or the more recent &#8220;prevention is better than cure&#8221;&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Key concepts</span><p id="par0120" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0125" class="elsevierStylePara elsevierViewall">CV calcification is part of CKD&#8211;MBD&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0130" class="elsevierStylePara elsevierViewall">The 2009 KDIGO guidelines &#40;and the 2015 publication of their preliminary controversies&#41; and the 2011 Spanish guidelines deem it reasonable to use information on vascular calcification to guide CKD&#8211;MBD management&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0135" class="elsevierStylePara elsevierViewall">Assessment of CV calcification should be performed in all patients&#44; or only in selected cases depending on the resources available in each health care system&#46; This is as long as the information on the absence&#47;presence&#47;degree of vascular calcification may affect treatment decisions&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0140" class="elsevierStylePara elsevierViewall">CV calcification is a potentially modifiable risk factor&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0145" class="elsevierStylePara elsevierViewall">CV calcification progression increases with certain treatments &#40;potential iatrogenic effects&#41; whereas other drugs seem to attenuate it&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0150" class="elsevierStylePara elsevierViewall">In <span class="elsevierStyleItalic">clinical</span> studies and meta-analyses&#44; non-calcium-based phosphate binders or calcimimetics seem to attenuate clinical progression of vascular calcification versus calcium-based P binders or standard treatment regimens for secondary hyperparathyroidism without calcimimetics&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0155" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Experimental</span> models demonstrate that different vitamin D compounds &#40;calcitriol vs&#46; <span class="elsevierStyleItalic">selective</span> vitamin D receptor activators&#59; e&#46;g&#46; paricalcitol&#41; have differential effects on vascular calcification&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0160" class="elsevierStylePara elsevierViewall">There is preliminary data on the influence of other drugs &#40;e&#46;g&#46; vitamin K&#44; bisphosphonates&#44; sodium thiosulfate&#44; or SNF472&#41; on vascular calcification progression in CKD patients&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0165" class="elsevierStylePara elsevierViewall">Although there is no definitive proof that personalised treatment based on the presence&#47;absence&#47;degree of vascular calcification improves survival of CKD patients&#44; a nihilistic attitude does not seem justified&#46;</p></li></ul></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Funding</span><p id="par0170" class="elsevierStylePara elsevierViewall">No funding was received to complete this work&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0175" class="elsevierStylePara elsevierViewall">Dr Jordi Bover received conference honorariums from AbbVie&#44; Amgen&#44; Genzyme&#44; and Shire&#44; as well as consultation fees from AbbVie&#44; Amgen&#44; Vifor&#47;Fresenius-Pharma&#44; Chugai&#44; Medice&#44; Genzyme&#47;Sanofi&#44; and Sanifit&#46; Dr J&#46;L&#46; G&#243;rriz received conference honorariums and grants from AbbVie&#46; Dr P&#46; Ure&#241;a received conference honorariums or consultation fees from Amgen&#44; AbbVie&#44; Genzyme-Sanofi&#44; Medice&#44; Hemotech&#44; and Fresenius&#46; Dr M&#46;J&#46; Lloret received conference honorariums from Sanofi and AbbVie&#46;</p></span></span>"
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          "titulo" => "Controlling traditional cardiovascular risk factors and vascular calcification"
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          "titulo" => "Control of CKD&#8211;MBD and vascular calcification-related risk factors"
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              "titulo" => "Recent information about phosphate binders"
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              "titulo" => "Controlling secondary hyperparathyroidism with calcimimetics"
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              "titulo" => "Calcidiol and vitamin D receptor activators"
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              "titulo" => "Vitamin K"
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              "titulo" => "Preliminary data on bisphosphonates&#44; thiosulfate&#44; and phytates"
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              "titulo" => "Other possible treatments"
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          "titulo" => "Conflicts of interest"
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          "titulo" => "Acknowledgements"
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    "fechaRecibido" => "2016-05-10"
    "fechaAceptado" => "2016-05-19"
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            0 => "Chronic kidney disease"
            1 => "Vascular calcification"
            2 => "Chronic kidney disease&#8211;mineral and bone disorders"
            3 => "Phosphate"
            4 => "Vitamin D"
            5 => "Calcimimetics"
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            0 => "Enfermedad renal cr&#243;nica"
            1 => "Calcificaci&#243;n vascular"
            2 => "<span class="elsevierStyleItalic">Chronic kidney disease-mineral and bone disorders</span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cardiovascular &#40;CV&#41; calcification is a highly prevalent condition at all stages of chronic kidney disease &#40;CKD&#41; and is directly associated with increased CV and global morbidity and mortality&#46; In the first part of this review&#44; we have shown that CV calcifications represent an important part of the CKD&#8211;MBD complex and are a superior predictor of clinical outcomes in our patients&#46; However&#44; it is also necessary to demonstrate that CV calcification is a modifiable risk factor including the possibility of decreasing &#40;or at least not aggravating&#41; its progression with iatrogenic manoeuvres&#46; Although&#44; strictly speaking&#44; only circumstantial evidence is available&#44; it is known that certain drugs may modify the progression of CV calcifications&#44; even though a direct causal link with improved survival has not been demonstrated&#46; For example&#44; non-calcium-based phosphate binders demonstrated the ability to attenuate the progression of CV calcification compared with the liberal use of calcium-based phosphate binders in several randomised clinical trials&#46; Moreover&#44; although only in experimental conditions&#44; selective activators of the vitamin D receptor seem to have a wider therapeutic margin against CV calcification&#46; Finally&#44; calcimimetics seem to attenuate the progression of CV calcification in dialysis patients&#46; While new therapeutic strategies are being developed &#40;i&#46;e&#46; vitamin K&#44; SNF472&#44; etc&#46;&#41;&#44; we suggest that the evaluation of CV calcifications could be a diagnostic tool used by nephrologists to personalise their therapeutic decisions&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La calcificaci&#243;n cardiovascular &#40;CV&#41; es una condici&#243;n muy prevalente en todos los estadios de la enfermedad renal cr&#243;nica &#40;ERC&#41; y se asocia directamente a una mayor morbimortalidad CV y global&#46; En la primera parte de esta revisi&#243;n hemos mostrado c&#243;mo las calcificaciones CV son una caracter&#237;stica destacada del complejo CKD-MBD &#40;<span class="elsevierStyleItalic">chronic kidney disease-mineral and bone disorders</span>&#41; as&#237; como un predictor superior de la evoluci&#243;n cl&#237;nica de nuestros pacientes&#46; No obstante&#44; es necesario tambi&#233;n demostrar que la calcificaci&#243;n CV es un factor de riesgo modificable y con la posibilidad&#44; como m&#237;nimo&#44; de poder disminuir su progresi&#243;n &#40;o al menos no agravarla&#41; con maniobras iatrog&#233;nicas&#46; Aunque estrictamente solo se disponga de evidencias circunstanciales&#44; sabemos que el uso de determinados f&#225;rmacos puede modificar la progresi&#243;n de las calcificaciones CV&#44; aunque no se ha demostrado un v&#237;nculo directo causal sobre la mejor&#237;a de la supervivencia&#46; En este sentido&#44; el uso de quelantes del f&#243;sforo no c&#225;lcicos ha demostrado reducir la progresi&#243;n de las calcificaciones CV en comparaci&#243;n con el uso liberal de quelantes c&#225;lcicos en varios ensayos cl&#237;nicos aleatorizados&#46; Por otra parte&#44; aunque solo a nivel experimental&#44; los activadores selectivos del receptor de la vitamina D parecen mostrar un mayor margen terap&#233;utico contra la calcificaci&#243;n CV&#46; Finalmente&#44; los calcimim&#233;ticos tambi&#233;n parece que podr&#237;an atenuar la progresi&#243;n de la calcificaci&#243;n CV en pacientes en di&#225;lisis&#46; Mientras se desarrollan nuevas estrategias terap&#233;uticas &#40;p&#46; ej&#46; vitamina K&#44; SNF472&#8230;&#41;&#44; proponemos que la valoraci&#243;n de las calcificaciones CV puede ser una herramienta usada por el nefr&#243;logo para la toma individualizada de decisiones terap&#233;uticas&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Bover J&#44; Ure&#241;a-Torres P&#44; G&#243;rriz JL&#44; Lloret MJ&#44; da Silva I&#44; Ruiz-Garc&#237;a C&#44; et al&#46; Calcificaciones cardiovasculares en la enfermedad renal cr&#243;nica&#58; Potenciales implicaciones terap&#233;uticas&#46; Nefrologia&#46; 2016&#59;36&#58;597&#8211;608&#46;</p>"
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            0 => array:3 [
              "identificador" => "bib0755"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Chronic kidney disease and the risks of death&#44; cardiovascular events&#44; and hospitalization"
                      "autores" => array:1 [
                        0 => array:2 [ …2]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa041031"
                      "Revista" => array:6 [
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                        "fecha" => "2004"
                        "volumen" => "351"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Detecci&#243;n de las calcificaciones cardiovasculares&#58; &#191;una herramienta &#250;til para el nefr&#243;logo&#63;"
                      "autores" => array:1 [
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                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.nefro.2016.05.021"
                      "Revista" => array:6 [
                        "tituloSerie" => "Nefrolog&#237;a"
                        "fecha" => "2016"
                        "volumen" => "36"
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              "etiqueta" => "3"
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                    ]
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                    0 => array:1 [
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                        "fecha" => "2011"
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                      "titulo" => "Con&#58; Vascular calcification is a surrogate marker&#44; but not the cause of ongoing vascular disease&#44; and it is not a treatment target in chronic kidney disease"
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/ndt/gfv021"
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                    0 => array:2 [
                      "titulo" => "Moderator&#39;s view&#58; treatment of vascular calcification is a physical impossibility&#44; so far"
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                      "titulo" => "Sevelamer attenuates the progression of coronary and aortic calcification in hemodialysis patients"
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                  "contribucion" => array:1 [
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                    0 => array:2 [
                      "titulo" => "Atorvastatin in patients with type 2 diabetes mellitus undergoing hemodialysis"
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                      "titulo" => "The effects of lowering LDL cholesterol with simvastatin plus ezetimibe in patients with chronic kidney disease &#40;Study of Heart and Renal Protection&#41;&#58; a randomised placebo-controlled trial"
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                      "titulo" => "Effect of intensive versus standard lipid-lowering treatment with atorvastatin on the progression of calcified coronary atherosclerosis over 12 months&#58; a multicenter&#44; randomized&#44; double-blind trial"
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                      "titulo" => "Treatment of asymptomatic adults with elevated coronary calcium scores with atorvastatin&#44; vitamin C&#44; and vitamin E&#58; the St&#46; Francis Heart Study randomized clinical trial"
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                      "titulo" => "Statins and cardiovascular primary prevention in CKD&#58; a meta-analysis"
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                      "doi" => "10.2215/CJN.07460714"
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                      "titulo" => "Are there ways to attenuate arterial calcification and improve cardiovascular outcomes in chronic kidney disease&#63;"
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                      "titulo" => "Bone metabolism and cardiovascular function update&#46; Cross link of hypertension&#44; bone loss and vascular calcification&#8212;common back grounds in renin angiotensin system with anti-aging aspect"
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                      "titulo" => "Sevelamer hydrochloride attenuates kidney and cardiovascular calcifications in long-term experimental uremia"
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                  ]
                  "host" => array:1 [
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        "texto" => "<p id="par0180" class="elsevierStylePara elsevierViewall">Dr Jordi Bover belongs to the Red Nacional RedinRen &#91;National Kidney Research Network&#93; &#40;RD06&#47;0016&#47;0001 and RD12&#47;0021&#47;0033&#41;&#44; the Red de Biobancos Nacional Espa&#241;ola &#91;Spanish National Biobank Network&#93; &#40;RD09&#47;0076&#47;00064&#41;&#44; and to the Grupo Catal&#225;n de Investigaci&#243;n AGAUR &#91;AGAUR Catalan Research Group&#93; &#40;2009 SGR-1116&#41;&#46; He also collaborates with the Fundaci&#243;n I&#241;igo &#193;lvarez de Toledo &#40;FRIAT&#41; &#91;I&#241;igo &#193;lvarez Foundation of Toledo&#93;&#46; We also wish to thank Ricardo Pellejero for his important bibliographic help&#46;</p>"
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Cardiovascular calcifications in chronic kidney disease: Potential therapeutic implications
Calcificaciones cardiovasculares en la enfermedad renal crónica: Potenciales implicaciones terapéuticas
Jordi Bovera,
Corresponding author
jbover@fundacio-puigvert.es

Corresponding author.
, Pablo Ureña-Torresb,c, José Luis Górrizd, María Jesús Lloreta, Iara da Silvaa, César Ruiz-Garcíaa, Pamela Changa, Mariano Rodrígueze, José Ballarína
a Servicio de Nefrología, Fundació Puigvert, IIB Sant Pau, RedinRen, Barcelona, Spain
b Departamento de Nefrología y Diálisis, Clinique du Landy, París, France
c Departamento de Fisiología Renal, Hospital Necker, Universidad de París Descartes, París, France
d Servicio de Nefrología, Hospital Universitario Dr. Peset, Valencia, Spain
e Servicio de Nefrología, Hospital Universitario Reina Sofía, IMIBIC, Universidad de Córdoba, Córdoba, Spain
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            "entidad" => "Servicio de Nefrolog&#237;a&#44; Fundaci&#243; Puigvert&#44; IIB Sant Pau&#44; RedinRen&#44; Barcelona&#44; Spain"
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            "identificador" => "aff0005"
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          1 => array:3 [
            "entidad" => "Departamento de Nefrolog&#237;a y Di&#225;lisis&#44; Clinique du Landy&#44; Par&#237;s&#44; France"
            "etiqueta" => "b"
            "identificador" => "aff0010"
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            "entidad" => "Departamento de Fisiolog&#237;a Renal&#44; Hospital Necker&#44; Universidad de Par&#237;s Descartes&#44; Par&#237;s&#44; France"
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            "identificador" => "aff0015"
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            "entidad" => "Servicio de Nefrolog&#237;a&#44; Hospital Universitario Reina Sof&#237;a&#44; IMIBIC&#44; Universidad de C&#243;rdoba&#44; C&#243;rdoba&#44; Spain"
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    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Calcificaciones cardiovasculares en la enfermedad renal cr&#243;nica&#58; Potenciales implicaciones terap&#233;uticas"
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Presently&#44; it is widely accepted that chronic kidney disease &#40;CKD&#41; is an independent cardiovascular &#40;CV&#41; risk factor and that its mortality rate increases exponentially as kidney function progressively deteriorates&#46;<a class="elsevierStyleCrossRef" href="#bib0755"><span class="elsevierStyleSup">1</span></a> In this context&#44; we have previously described the types of CV calcification&#44;<a class="elsevierStyleCrossRefs" href="#bib0760"><span class="elsevierStyleSup">2&#44;3</span></a> its association with CV events&#44; mortality&#44;<a class="elsevierStyleCrossRef" href="#bib0760"><span class="elsevierStyleSup">2</span></a> and why we justify assessing vascular calcification in routine nephrology clinical practice&#46;<a class="elsevierStyleCrossRef" href="#bib0760"><span class="elsevierStyleSup">2</span></a> Nonetheless&#44; it is important to demonstrate beforehand that CV calcification is also a modifiable risk factor with at least the possibility of decreasing its progression and not aggravating it in the case of not being able to reverse it&#46; Then&#44; the objective of the second part of this review&#44; is to explain how CV calcification is a modifiable risk factor despite being a late and secondary phenomenon and only circumstancial evidence available&#46;<a class="elsevierStyleCrossRefs" href="#bib0770"><span class="elsevierStyleSup">4&#8211;6</span></a> Certainly CV calcification is a risk factor that&#44; unfortunately&#44; we may contribute to by adding unwanted iatrogenic effects&#46;<a class="elsevierStyleCrossRefs" href="#bib0780"><span class="elsevierStyleSup">6&#8211;9</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Controlling traditional cardiovascular risk factors and vascular calcification</span><p id="par0010" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Observational</span> studies have shown that the differential use of drugs acting on the CV system such as statins&#44; &#946;-blockers&#44; calcium channel antagonists&#44; and angiotensin-converting enzyme &#40;ACE&#41; inhibitors&#47;angiotensin-II-receptor blockers &#40;ARB&#41; are associated with a lower risk of CV events and death in CKD patients&#46;<a class="elsevierStyleCrossRef" href="#bib0800"><span class="elsevierStyleSup">10</span></a> However&#44; there is no single drug that clearly demonstrates an improvement in survival in dialysis patients&#46;<a class="elsevierStyleCrossRef" href="#bib0805"><span class="elsevierStyleSup">11</span></a> The treatment of CV risk factors for atherosclerosis&#44; such as hyperlipidaemia&#44; does not improve the survival of these patients&#44;<a class="elsevierStyleCrossRefs" href="#bib0810"><span class="elsevierStyleSup">12&#44;13</span></a> and only the reduction of LDL cholesterol with simvastatin plus ezetimibe decreased the incidence of CV events in a wide range of advanced CKD patients&#44; but without demonstrating a benefit in overall survival&#46;<a class="elsevierStyleCrossRef" href="#bib0820"><span class="elsevierStyleSup">14</span></a> Treating hyperlipidaemia with statins has also failed to reduce vascular calcification&#46;<a class="elsevierStyleCrossRefs" href="#bib0825"><span class="elsevierStyleSup">15&#44;16</span></a> Only one recent meta-analysis has indicated that using statins is effective in the primary prevention of CV disease in CKD&#46;<a class="elsevierStyleCrossRef" href="#bib0835"><span class="elsevierStyleSup">17</span></a> Moreover&#44; there are very limited or non-existent data available on the effect of control of diabetes and blood pressure&#44; as well as quitting tobacco on vascular calcification or the CV risk in the CKD population&#46;<a class="elsevierStyleCrossRef" href="#bib0840"><span class="elsevierStyleSup">18</span></a> Only in new experimental models&#44; ARBs have been demonstrated to have powerful protective effects on vascular calcification by interrupting vascular osteogenesis&#46; The combination of statins and ARBs produces potent synergistic protective effects against vascular calcification in CKD that is beyond the control of blood pressure&#46;<a class="elsevierStyleCrossRefs" href="#bib0845"><span class="elsevierStyleSup">19&#8211;22</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Control of CKD&#8211;MBD and vascular calcification-related risk factors</span><p id="par0015" class="elsevierStylePara elsevierViewall">Many CKD&#8211;MBD-related treatments&#44; such as phosphate &#40;P&#41; binders&#44; vitamin D derivatives&#44; calcimimetics&#44; and others&#44; have been widely demonstrated to influence on <span class="elsevierStyleItalic">experimental</span> vascular calcification and point to the possibility of being able to modify its <span class="elsevierStyleItalic">clinical</span> progression&#44; including dialysis patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0785"><span class="elsevierStyleSup">7&#44;23&#8211;26</span></a> Nevertheless&#44; it should be recognised that there is no definitive proof in any randomised clinical study showing that a single drug in this therapeutic area has an irrefutable impact on major events in CKD patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0790"><span class="elsevierStyleSup">8&#44;9</span></a></p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Recent information about phosphate binders</span><p id="par0020" class="elsevierStylePara elsevierViewall">Hyperphosphataemia is recognised as an independent CV risk factor&#46; Abnormal P metabolism occurs early in CKD and there is a general consensus that it is one of the most important factors contributing in the onset of CV calcification&#44; along with changes in intra- and extracellular Ca content&#46; Both have a strong influence on the vascular smooth muscle cell &#40;VSMC&#41; function&#46;<a class="elsevierStyleCrossRefs" href="#bib0885"><span class="elsevierStyleSup">27&#44;28</span></a> Since the experiments by Jono et al&#46;<a class="elsevierStyleCrossRef" href="#bib0885"><span class="elsevierStyleSup">27</span></a> and Giachelli et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0895"><span class="elsevierStyleSup">29</span></a> nephrologists have recognised the need to avoid P overload&#44; not only as a promoter of secondary hyperparathyroidism&#44; but also because of its direct effects on CV health&#44;<a class="elsevierStyleCrossRefs" href="#bib0900"><span class="elsevierStyleSup">30&#8211;32</span></a> including its potent proinflammatory and oxidative effects<a class="elsevierStyleCrossRefs" href="#bib0915"><span class="elsevierStyleSup">33&#44;34</span></a> that may affect even patients with mild CKD and possibly the general population&#46;<a class="elsevierStyleCrossRef" href="#bib0925"><span class="elsevierStyleSup">35</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Goodman et al&#46;&#8217;s initial publication in adolescents on dialysis&#44; showed that they already had vascular calcifications and that the amount of Ca they ingested was double than those without calcifications&#46; This information started a broad debate about the different binders &#40;calcium vs&#46; non-calcium&#41; that has not been fully resolved yet&#46;<a class="elsevierStyleCrossRefs" href="#bib0930"><span class="elsevierStyleSup">36&#8211;38</span></a> Several randomised studies conducted in adults on dialysis have demonstrated that CV calcification progression was truly modifiable by choosing non-calcium P binders&#46;<a class="elsevierStyleCrossRefs" href="#bib0785"><span class="elsevierStyleSup">7&#44;39&#8211;42</span></a> However these results are not consistent&#46;<a class="elsevierStyleCrossRef" href="#bib0965"><span class="elsevierStyleSup">43</span></a> In some clinical trials&#44; negative results have been attributed to a patient population that had a higher number of CV risk factors&#59;<a class="elsevierStyleCrossRefs" href="#bib0970"><span class="elsevierStyleSup">44&#44;45</span></a> other studies faced obstacles such as a small sample size or the use of high Ca concentrations in the dialysate bath in many patients&#46;<a class="elsevierStyleCrossRef" href="#bib0980"><span class="elsevierStyleSup">46</span></a> Therefore&#44; despite the fact that the &#8220;Dialysis Clinical Outcomes Revisited&#8221; &#40;DCOR&#41; study found that using sevelamer HCl in dialysis patients did not significantly improve the mortality rates&#44;<a class="elsevierStyleCrossRefs" href="#bib0985"><span class="elsevierStyleSup">47&#44;48</span></a> the 2009 KDIGO guidelines proposed a restriction of Ca-based P-binder dose in the presence of arterial calcification &#40;guideline 4&#46;1&#46;5&#59; 2C&#41;&#44; at least until more conclusive studies are conducted&#46;<a class="elsevierStyleCrossRef" href="#bib0900"><span class="elsevierStyleSup">30</span></a> This represents a step forward in comparison to the previous American guidelines<a class="elsevierStyleCrossRef" href="#bib0995"><span class="elsevierStyleSup">49</span></a> &#40;K-DOQI 2003&#41; where&#44; curiously&#44; the Ca-based P binders were limited only to cases with <span class="elsevierStyleItalic">severe</span> vascular calcification &#40;a situation that may be too advanced to modify the harmful consequences&#41;&#46; Although the DCOR study did not strictly demonstrate the superiority of sevelamer versus calcium-based binders&#44; it cannot be said that Ca-based P binders are safe&#46;<a class="elsevierStyleCrossRefs" href="#bib0910"><span class="elsevierStyleSup">32&#44;50</span></a> With need to take into consideration also economic aspects&#44;<a class="elsevierStyleCrossRef" href="#bib1005"><span class="elsevierStyleSup">51</span></a> at least these studies have made the nephrology community aware that indiscriminately using calcium-based binders may be inappropriate and that it might be safer to limit Ca intake to less than 1<span class="elsevierStyleHsp" style=""></span>g&#47;day in CKD patients&#46;<a class="elsevierStyleCrossRef" href="#bib1010"><span class="elsevierStyleSup">52</span></a> A recent metabolic study demonstrated that even in stage 3b-4 CKD patients &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&#59; mean GFR 36<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#59; mean P<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#46;8<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; administering 1&#46;5<span class="elsevierStyleHsp" style=""></span>g of calcium carbonate converted a neutral Ca balance into a largely positive balance&#44;<a class="elsevierStyleCrossRef" href="#bib1015"><span class="elsevierStyleSup">53</span></a> although it is unknown whether this altered balance is temporal&#44; by inducing adaptation phenomena&#44; or whether this excess of Ca ends up being deposited in extraosseous tissues&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">More recent studies in dialysis patients have shown that the progression of vascular calcification was attenuated not only by sevelamer but also bylanthanum and&#44; in two small pilot studies&#44; by the use of P binders containing magnesium&#46;<a class="elsevierStyleCrossRefs" href="#bib1020"><span class="elsevierStyleSup">54&#8211;59</span></a> A recent meta-analysis has also reinforced the idea that it may be possible to attenuate the progression of vascular calcification with non-calcium P binders&#46;<a class="elsevierStyleCrossRef" href="#bib1050"><span class="elsevierStyleSup">60</span></a> Moreover&#44; in another randomised&#44; open-label&#44; parallel groups study including 466 Italian patients who were starting haemodialysis&#44; sevelamer improved <span class="elsevierStyleItalic">survival</span> as compared with calcium-based P binders&#44;<a class="elsevierStyleCrossRef" href="#bib1055"><span class="elsevierStyleSup">61</span></a> although it could not be established a direct relationship between the Ca load and worse outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib1055"><span class="elsevierStyleSup">61</span></a> Furthermore&#44; in another recent meta-analysis&#44; non-calcium P binders were associated with a criticised reduction of overall mortality risk &#40;22&#37;&#41; in CKD patients &#40;mostly dialysis patients treated with sevelamer&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0770"><span class="elsevierStyleSup">4</span></a> in contrast to the negative results from other previous meta-analyses&#46;<a class="elsevierStyleCrossRefs" href="#bib0935"><span class="elsevierStyleSup">37&#44;62</span></a> Nonetheless&#44; in some of these studies high doses of binders were administered to achieve protocol objectives&#59; therefore&#44; these results should be extrapolated with caution to those situations in which moderate doses of Ca-based binders are used or those cases in which both types of binders &#40;with and without Ca&#41; are being administered&#46;<a class="elsevierStyleCrossRefs" href="#bib1065"><span class="elsevierStyleSup">63&#44;64</span></a> Another study found that normal individuals and patients with stage 3b-4 CKD had a slightly negative or neutral Ca balance while eating a 800<span class="elsevierStyleHsp" style=""></span>mg&#47;day Ca diet&#44; however with a 2000<span class="elsevierStyleHsp" style=""></span>mg&#47;day diet&#44; the normal individuals had a slightly positive balance and the CKD patients had a clearly positive balance&#44; at least during the 9 days of the study&#46;<a class="elsevierStyleCrossRef" href="#bib1075"><span class="elsevierStyleSup">65</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Lastly&#44; a randomised&#44; multi-centre&#44; open-label pilot study conducted in 212 outpatients with stage 3&#8211;4 CKD recruited over a maximum of 36 months demonstrated that treatment with sevelamer to maintain plasma P within the normal range&#44; was associated with a significantly lower incidence of de novo CAC among patients with no baseline CV disease &#40;12&#46;8&#37; vs&#46; 81&#46;8&#37; for sevelamer and Ca carbonate&#44; respectively&#41;&#44; as well as slower CAC progression among the patients with evidence of CAC at the start of the study&#46;<a class="elsevierStyleCrossRef" href="#bib1080"><span class="elsevierStyleSup">66</span></a> A significant <span class="elsevierStyleItalic">regression</span> of CAC was also detected in 24 patients treated with sevelamer&#44; and only in 2 patients treated with Ca&#46; The overall mortality and the final composite endpoint of death and dialysis inception were lower in the patients assigned to sevelamer&#46;<a class="elsevierStyleCrossRef" href="#bib1080"><span class="elsevierStyleSup">66</span></a> This study did not include a placebo arm and included patients with moderate hyperphosphataemia &#40;4&#46;84<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;3<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41;&#46; Conversely&#44; in another&#44; smaller randomised study of 148 patients with moderate CKD &#40;GFR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>20&#8211;45<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> with a mean P of 4&#46;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; comparison of Ca phosphate binders&#44; sevelamer&#44; and lanthanum vs&#46; placebo showed a completely unexpected increase in vascular calcification in all groups&#44; even though in the post hoc analysis&#44; the degree of progression was higher in the Ca arm&#46;<a class="elsevierStyleCrossRef" href="#bib1085"><span class="elsevierStyleSup">67</span></a> In another study&#44;<a class="elsevierStyleCrossRef" href="#bib1090"><span class="elsevierStyleSup">68</span></a> rosuvastatin and sevelamer did not delay the progression of vascular calcification in CKD patients not yet in dialysis&#46; Therefore&#44; despite the demonstrated potential benefit for survival&#44; at least in some CKD patients&#44; additional studies are needed to define the effects of P binders in CKD patients before starting dialysis&#46; In fact&#44; this is one of the areas of nephrology in which we have less evidence and limited alternatives&#46; A large controversy has been generated on whether P binders should be prescribed in stage 3&#8211;4 CKD&#44;<a class="elsevierStyleCrossRefs" href="#bib1095"><span class="elsevierStyleSup">69&#8211;71</span></a> this controversy illustrate the extreme necessity to conduct prospective clinical studies measuring hard events&#46;<a class="elsevierStyleCrossRefs" href="#bib1095"><span class="elsevierStyleSup">69&#8211;71</span></a> According to the prescribing information&#44; P binders without Ca should be restricted to CKD patients not in dialysis if serum P is greater than 1&#46;78<span class="elsevierStyleHsp" style=""></span>mmol&#47;l &#40;5&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41;&#46; Nevertheless&#44; it should be noted that in the recent controversies on the KDIGO guidelines&#44;<a class="elsevierStyleCrossRef" href="#bib1065"><span class="elsevierStyleSup">63</span></a> the concern about Ca overload as a risk factor for progression of vascular calcification in CKD was clearly emphasised&#46;<a class="elsevierStyleCrossRefs" href="#bib0935"><span class="elsevierStyleSup">37&#44;66&#44;67&#44;72&#44;73</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Controlling secondary hyperparathyroidism with calcimimetics</span><p id="par0040" class="elsevierStylePara elsevierViewall">In addition to the experimental data showing a neutral or protective effect of calcimimetics on uraemic <span class="elsevierStyleItalic">atherosclerosis</span> or vascular calcification&#44;<a class="elsevierStyleCrossRefs" href="#bib0870"><span class="elsevierStyleSup">24&#44;74&#44;75</span></a> a randomised clinical trial recently demonstrated that cinacalcet&#44; along with low-doses of vitamin D analogues&#44; can attenuate the progression of vascular calcification in dialysis patients versus the standard treatment &#40;different doses of vitamin D analogues or binders&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0875"><span class="elsevierStyleSup">25</span></a> Although the study did not clearly demonstrate a significant benefit &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;07&#41;&#44; there was a clear tendency towards decreased progression of CAC&#44; thoracic aorta calcification&#44; and cardiac valve calcification in the group treated with calcimimetics&#46; This effect was especially significant in those patients adhering to the initially designed protocol maintaining a low dose of vitamin D analogues&#46;<a class="elsevierStyleCrossRef" href="#bib0880"><span class="elsevierStyleSup">26</span></a> Similar results were described in an observational study conducted in Japan&#46;<a class="elsevierStyleCrossRef" href="#bib1130"><span class="elsevierStyleSup">76</span></a> Furthermore&#44; another retrospective study including dialysis patients on intravenous vitamin D therapy &#40;a surrogate marker for secondary hyperparathyroidism&#41;&#44; the prescription of calcimimetics was associated with a significant improvement in survival&#46;<a class="elsevierStyleCrossRef" href="#bib1135"><span class="elsevierStyleSup">77</span></a> However&#44; the EVOLVE study&#44;<a class="elsevierStyleCrossRef" href="#bib1140"><span class="elsevierStyleSup">78</span></a> comparing calcimimetics vs&#46; standard therapy in the largest study conducted in haemodialysis patients &#40;3883&#41;&#44; showed that cinacalcet did <span class="elsevierStyleItalic">not</span> significantly reduce the risk of death or CV events in dialysis patients with moderate to severe secondary hyperparathyroidism after an <span class="elsevierStyleItalic">unadjusted</span> intention-to-treat statistical analysis&#46; Similarly&#44; in a recent meta-analysis&#44; based essentially on the above study&#44; calcimimetics did not seem to improve CV or overall mortality&#46;<a class="elsevierStyleCrossRef" href="#bib1145"><span class="elsevierStyleSup">79</span></a> As a result&#44; as previously observed with sevelamer in the DCOR study&#44;<a class="elsevierStyleCrossRefs" href="#bib0985"><span class="elsevierStyleSup">47&#44;48</span></a> it was not possible to definitively establish a direct relation between therapeutic measures that potentially attenuate vascular calcification progression in dialysis patients and benefits for survival&#46; However&#44; it is important to note that&#44; in addition to other <span class="elsevierStyleItalic">nominally</span> significant beneficial effects associated with sevelamer and cinacalcet&#44;<a class="elsevierStyleCrossRefs" href="#bib0985"><span class="elsevierStyleSup">47&#44;48&#44;78</span></a> it was observed in both studies that age had a highly significant interaction on the treatment effect&#46; Both drugs significantly reduced mortality in a <span class="elsevierStyleItalic">predefined</span> subgroup of patients over 65 years of age&#59; this result is likely due to the higher statistical power inherent to a higher number of CV events and mortality in this age group&#46;<a class="elsevierStyleCrossRefs" href="#bib1140"><span class="elsevierStyleSup">78&#44;80</span></a> A similar interaction with age was observed with lanthanum carbonate&#46;<a class="elsevierStyleCrossRef" href="#bib1155"><span class="elsevierStyleSup">81</span></a> In addition&#44; in the general population a significant association between vascular calcification and kidney function has also been recently described in the elderly&#44; but not in younger individuals&#46;<a class="elsevierStyleCrossRef" href="#bib1160"><span class="elsevierStyleSup">82</span></a> It is important to note that&#44; in the case of the EVOLVE study&#44; cinacalcet <span class="elsevierStyleItalic">did</span> significantly reduce the risk of death or major CV events in dialysis patients in a second predefined intention-to-treat analysis when <span class="elsevierStyleItalic">adjusted</span> for age or other factors&#44; as well as other complex sensitivity analyses&#44; despite the excessive number of <span class="elsevierStyleItalic">drop-ins</span> and <span class="elsevierStyleItalic">drop-outs&#46;</span><a class="elsevierStyleCrossRefs" href="#bib1140"><span class="elsevierStyleSup">78&#44;83</span></a> Various beneficial effects of cinacalcet have also been described in post hoc studies&#44;<a class="elsevierStyleCrossRefs" href="#bib1165"><span class="elsevierStyleSup">83&#8211;88</span></a> including decreased mortality in non-atherosclerotic events &#40;including sudden death and heart failure&#41; in patients treated with cinacalcet&#46;<a class="elsevierStyleCrossRef" href="#bib1180"><span class="elsevierStyleSup">86</span></a> We therefore believe that the EVOLVE study should not be considered a <span class="elsevierStyleItalic">negative</span> study&#44; but rather an inconclusive&#44; non-definitive study&#44; since the absence of evidence cannot in any way be considered evidence of absence&#46;<a class="elsevierStyleCrossRefs" href="#bib1000"><span class="elsevierStyleSup">50&#44;83</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Lastly&#44; it is important to emphasise that calcimimetics have also been successfully used to treat some cases of calciphylaxis&#46;<a class="elsevierStyleCrossRefs" href="#bib1185"><span class="elsevierStyleSup">87&#44;89</span></a> Calciphylaxis episodes occurred significantly less often in the group of patients treated with cinacalcet in the EVOLVE study and in a post hoc analysis&#46;<a class="elsevierStyleCrossRefs" href="#bib1140"><span class="elsevierStyleSup">78&#44;87</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Calcidiol and vitamin D receptor activators</span><p id="par0050" class="elsevierStylePara elsevierViewall">Low levels of calcidiol &#40;25-OH vitamin D&#41; have been directly associated with the presence and progression of vascular calcification and represent a new CV risk marker on their own&#46;<a class="elsevierStyleCrossRefs" href="#bib1200"><span class="elsevierStyleSup">90&#44;91</span></a> Although it may only be a mere bystander maintaining &#8220;normal&#8221; levels seems to be desirable&#46; Spanish guidelines<a class="elsevierStyleCrossRef" href="#bib1210"><span class="elsevierStyleSup">92</span></a> recommended to maintain normal levels of calcidiol to reduce vascular calcification progression&#44; maintain a normal bone turnover&#44;<a class="elsevierStyleCrossRefs" href="#bib0780"><span class="elsevierStyleSup">6&#44;91</span></a> and provide the other pleiotropic effects described for vitamin D&#44; including vascular regeneration&#44; anti-inflammatory effects&#44; and anti-renin activity&#44; among others&#46;<a class="elsevierStyleCrossRefs" href="#bib1215"><span class="elsevierStyleSup">93&#8211;96</span></a> However&#44; there are no <span class="elsevierStyleItalic">prospective</span>&#44; randomised clinical trials that have assessed the impact of <span class="elsevierStyleItalic">native</span> vitamin D or vitamin D receptor &#40;VDR&#41; activators such as calcitriol&#44; alfacalcidol&#44; paricalcitol&#44; or others on human vascular calcification&#46; Experimental studies have demonstrated differential effects between calcitriol and other VDR activators on extraosseous calcification&#46; Calcitriol is a classic&#44; direct&#44; dose-dependent inducer of <span class="elsevierStyleItalic">experimental</span> vascular calcification&#44; especially in the presence of high P exposure or as the result of systemic vitamin D-induced Ca and P accumulation&#44; more than a local effect on the artery wall&#46;<a class="elsevierStyleCrossRefs" href="#bib0870"><span class="elsevierStyleSup">24&#44;74&#44;97</span></a> Furthermore&#44; the lowest doses of both calcitriol and paricalcitol seem to protect against vascular calcification&#44; likely through klotho restoration and osteopontin expression&#46;<a class="elsevierStyleCrossRefs" href="#bib1240"><span class="elsevierStyleSup">98&#8211;100</span></a> Therefore&#44; the presence of a bimodal effect of the VDR activators regarding vascular calcification regulation can be postulated&#46; In general&#44; experimental data supporting lower toxicity with some VDR activators versus calcitriol are not consistent between studies&#44; but they seem to support the assertion that there is reduced calcification induction with other selective VDR activators such as paricalcitol&#46;<a class="elsevierStyleCrossRefs" href="#bib0870"><span class="elsevierStyleSup">24&#44;74&#44;95&#44;101</span></a> For example&#44; paricalcitol&#44; in contrast to calcitriol&#44; decreases Wnt&#47;&#946;-catenin pathway activation&#44; the most important signalling pathway in transdifferentiating VSMC into osteoblasts&#46;<a class="elsevierStyleCrossRef" href="#bib1260"><span class="elsevierStyleSup">102</span></a> Paricalcitol may also have an effect on earlier stages of vascular disease&#59; it is unknown whether this is true of other VDR activators&#46;<a class="elsevierStyleCrossRef" href="#bib1265"><span class="elsevierStyleSup">103</span></a> Furthermore&#44; several <span class="elsevierStyleItalic">retrospective</span> studies have described a consistent and solid benefit on survival for haemodialysis patients with <span class="elsevierStyleItalic">selective</span> VDR activators<a class="elsevierStyleCrossRefs" href="#bib1270"><span class="elsevierStyleSup">104&#44;105</span></a> and&#44; although it has been questioned&#44;<a class="elsevierStyleCrossRef" href="#bib1280"><span class="elsevierStyleSup">106</span></a> the benefit seems to be more pronounced in the low-dose range and among patients who received selective VDR activators&#46;<a class="elsevierStyleCrossRefs" href="#bib0840"><span class="elsevierStyleSup">18&#44;104</span></a> Lastly&#44; a recent meta-analysis including 14 observational studies &#40;194&#44;932 patients&#41; showed that VDR activator therapies are associated with a lower mortality in CKD patients&#44;<a class="elsevierStyleCrossRef" href="#bib1285"><span class="elsevierStyleSup">107</span></a> although there is no consistency between the different meta-analyses&#46;<a class="elsevierStyleCrossRef" href="#bib1290"><span class="elsevierStyleSup">108</span></a> To date there is no published prospective clinical trial assessing the effect of VDR activators on survival so the previous potential beneficial results could be confirmed&#44; although by no means this beneficial effect should be rejected either&#46;<a class="elsevierStyleCrossRef" href="#bib1295"><span class="elsevierStyleSup">109</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Vitamin K</span><p id="par0055" class="elsevierStylePara elsevierViewall">Vitamin K is necessary as a cofactor in the process of converting inactive decarboxylated extracellular matrix proteins into active carboxylated proteins&#46; Osteocalcin and Matrix Gla protein &#40;MGP&#41; require the presence of vitamin K for activation and warfarin&#44; as a vitamin K antagonist&#44; inhibits coagulation&#44; but long-term use can promote vascular calcification and overregulation of decarboxylated MGP&#46;<a class="elsevierStyleCrossRefs" href="#bib1300"><span class="elsevierStyleSup">110&#44;111</span></a> The association between CAC and vitamin K antagonist therapy was already known in patients with low-risk atrial fibrillation<a class="elsevierStyleCrossRef" href="#bib1310"><span class="elsevierStyleSup">112</span></a> and&#44; recently&#44; G&#243;rriz et al&#46; confirmed the independent association between the use of oral anticoagulants and vascular calcification&#44; even in CKD patients not on dialysis&#46;<a class="elsevierStyleCrossRef" href="#bib1315"><span class="elsevierStyleSup">113</span></a> Experimental work shows that vitamin K is able to revert warfarin-induced medial calcinosis of elastin<a class="elsevierStyleCrossRef" href="#bib1320"><span class="elsevierStyleSup">114</span></a> and&#44; since vitamin K deficiency is common in dialysis&#44; it is not surprising to see that currently there are several prospective clinical trials evaluating the effect of vitamin K supplementation on CAC progression in CKD and haemodialysis patients&#46;<a class="elsevierStyleCrossRef" href="#bib1325"><span class="elsevierStyleSup">115</span></a> It is possible that the new oral anticoagulants&#44; now available for patients with atrial fibrillation or acute coronary syndrome&#44; may become a therapeutic alternative&#46;<a class="elsevierStyleCrossRefs" href="#bib1330"><span class="elsevierStyleSup">116&#44;117</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Preliminary data on bisphosphonates&#44; thiosulfate&#44; and phytates</span><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Bisphosphonates</span> have also been successfully used &#8220;off label&#8221; to treat calciphylaxis&#46;<a class="elsevierStyleCrossRef" href="#bib1340"><span class="elsevierStyleSup">118</span></a> In addition to the experimental data showing that treatment with pamidronate or etidronate prevents vascular calcification&#44;<a class="elsevierStyleCrossRef" href="#bib1345"><span class="elsevierStyleSup">119</span></a> oral or parenteral etidronate can delay CAC progression and aortic valve calcification&#44; although not all new-generation of bisphosphonates have been shown to reduce calcifications&#46;<a class="elsevierStyleCrossRefs" href="#bib1350"><span class="elsevierStyleSup">120&#8211;123</span></a> In this line&#44; it is worth to mention that the vessel wall possesses a &#8220;natural form of bisphosphonates&#8221;&#44; pyrophosphates&#44; which antagonise alkaline phosphatase and are one of the most effective anticalcifying factors of the vascular wall&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">A randomised clinical trial including 108 hypercholesterolaemic patients revealed that combination therapy with atorvastatin plus etidronate for 12 months significantly reduced atheroma plaques in thoracic and abdominal aorta&#46;<a class="elsevierStyleCrossRef" href="#bib1370"><span class="elsevierStyleSup">124</span></a> Since the vascular effects of bisphosphonates cannot be separated from adequate bone formation&#44; the administration to CKD patients may promote the development or aggravation of adynamic bone disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0900"><span class="elsevierStyleSup">30&#44;125&#44;126</span></a> As a result&#44; a bone biopsy is recommended before using bisphosphonates in patients with a GFR<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> unless a <span class="elsevierStyleItalic">high</span>-turnover bone disease is undeniably present&#44;<a class="elsevierStyleCrossRef" href="#bib0900"><span class="elsevierStyleSup">30</span></a> or in the context of a potentially fatal disease such as calciphylaxis&#46;<a class="elsevierStyleCrossRef" href="#bib1340"><span class="elsevierStyleSup">118</span></a> A similar strategy should likely be applied to new therapies such as denosumab and romosozumab&#44; although the half-life of these drugs in bone is certainly lower&#46;<a class="elsevierStyleCrossRef" href="#bib1385"><span class="elsevierStyleSup">127</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Sodium thiosulfate</span> has been introduced into the therapeutic arsenal against calciphylaxis&#46;<a class="elsevierStyleCrossRef" href="#bib1390"><span class="elsevierStyleSup">128</span></a> It may also attenuate the CAC progression rate versus the non-treatment group&#44; but with a significant decrease in hip bone mineral density&#46;<a class="elsevierStyleCrossRefs" href="#bib1395"><span class="elsevierStyleSup">129&#44;130</span></a> Sodium thiosulfate and other binding agents have been demonstrated to be potentially useful in reversing vessel medial calcification&#44;<a class="elsevierStyleCrossRef" href="#bib1405"><span class="elsevierStyleSup">131</span></a> however the mechanism by which sodium thiosulfate reduces calcification is not fully understood&#46;<a class="elsevierStyleCrossRefs" href="#bib1395"><span class="elsevierStyleSup">129&#44;132</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Given the importance of this topic&#44; new drugs are being developed that could act as vascular calcification inhibitors such as <span class="elsevierStyleItalic">SNF472</span>&#44;<a class="elsevierStyleCrossRef" href="#bib1415"><span class="elsevierStyleSup">133</span></a> an intravenous formulation of myoinositol hexaphosphate &#40;phytate&#41; that prevents hydroxyapatite crystals from forming and growing&#46;<a class="elsevierStyleCrossRefs" href="#bib1420"><span class="elsevierStyleSup">134&#44;135</span></a> It also acts as a calcification antagonist that could be effective as a therapy for treating CV calcification in CKD patients and in calciphylaxis&#46;<a class="elsevierStyleCrossRef" href="#bib1415"><span class="elsevierStyleSup">133</span></a> SNF472 acts through a physicochemical mechanism&#44; binding to the forming or growing crystal&#46;<a class="elsevierStyleCrossRef" href="#bib1430"><span class="elsevierStyleSup">136</span></a> Its high efficacy in animal models and short half-life give it a suitable safety and efficacy profile in CKD&#44; but this will have to be confirmed in long-term clinical studies&#46; At this time it is in phase 1b&#47;2 development&#46;<a class="elsevierStyleCrossRef" href="#bib1430"><span class="elsevierStyleSup">136</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Other possible treatments</span><p id="par0080" class="elsevierStylePara elsevierViewall">There are no studies investigating the effects of <span class="elsevierStyleItalic">parathyroidectomy</span> on the progression or regression of vascular calcification that meet the pre-established inclusion criteria for the 2009 KDIGO guidelines revision&#46; Similarly&#44; to date there are no new data available beyond the classic indication for parathyroidectomy in the form of calciphylaxis associated with severe secondary hyperparathyroidism&#46; In <span class="elsevierStyleItalic">kidney transplantation</span>&#44; few studies have been able to demonstrate stabilisation or attenuation&#44; but do not completely stop&#44; the rate of progression of vascular calcification&#44; despite the significant improvement in kidney function and mineral metabolism parameters&#46;<a class="elsevierStyleCrossRefs" href="#bib1435"><span class="elsevierStyleSup">137&#8211;140</span></a> However&#44; many other CV risk factors&#44; either prior to or within the context of transplantation&#44; may play an additional role in this specific population&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">General recommendations</span><p id="par0085" class="elsevierStylePara elsevierViewall">There are no studies demonstrating that the presence&#47;absence&#47;degree of vascular calcification is associated with changes in the prognosis of CKD patients&#59; however&#44; in this second part of the review we have discussed the extensive evidence&#44; especially in dialysis patients&#44; that some of the treatments used for CKD&#8211;MBD may enhance vascular calcification progression&#44; at least when the calcifications are already present&#46;<a class="elsevierStyleCrossRefs" href="#bib0785"><span class="elsevierStyleSup">7&#44;25</span></a> It is known that vascular calcification is a late&#44; and likely secondary&#44; phenomenon&#44; preceded by inflammation&#44; among other factors&#44; that could be primarily treated by preventing CV disease at earlier stages&#46;<a class="elsevierStyleCrossRef" href="#bib0770"><span class="elsevierStyleSup">4</span></a> However&#44; given the lack of proven strategies for early prevention&#44; along with the serious possibility of inducing iatrogenic effects&#44; makes us believe that a nihilistic attitude towards vascular calcification is not appropriate&#44; considering it as an impossibility to treat&#44; since it has been demonstrated that we can both attenuate its progression or even turn it worse&#46;<a class="elsevierStyleCrossRefs" href="#bib0775"><span class="elsevierStyleSup">5&#44;7&#8211;9&#44;25&#44;50</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Awaiting the difficult viability of a randomised&#44; multi-interventionist clinical trial independent from drug industry&#44; we recognise that CV calcification does not meet the requirements to recommend general screening&#46;<a class="elsevierStyleCrossRefs" href="#bib1455"><span class="elsevierStyleSup">141&#44;142</span></a> However&#44; given the predictive capability of CV calcification and its <span class="elsevierStyleItalic">progression</span>&#44; we believe that CKD patients with vascular calcification would not only require more continuous CV follow-up and monitoring &#40;not only for their calcification&#41;&#44; but would likely benefit from additional initiatives to control the traditional and non-traditional CV risk factors&#46;<a class="elsevierStyleCrossRefs" href="#bib0780"><span class="elsevierStyleSup">6&#44;143</span></a> Among these initiatives we should include more intensive control of plasma P&#44; avoid P overload&#44; administration of fewer treatments or high doses of drugs that could promote CV calcification&#44; which may result in increasing the value of certain treatments above their absolute cost&#46;<a class="elsevierStyleCrossRefs" href="#bib0785"><span class="elsevierStyleSup">7&#44;37&#44;78&#44;83&#44;95&#44;144</span></a> The recent arrival of some generics will undoubtedly help to reduce certain economic burdens while waiting for new evidence&#46;<a class="elsevierStyleCrossRefs" href="#bib0790"><span class="elsevierStyleSup">8&#44;9</span></a> Knowing the presence&#47;absence&#47;degree of CV calcification would improve the individual CV risk assessment&#44; and would help to choose the safest treatment option to avoid the risk of increasing the burden and progression of CV calcification&#59; always considering the high risk of CKD patients and the indirect economic consequences&#46;<a class="elsevierStyleCrossRef" href="#bib0780"><span class="elsevierStyleSup">6</span></a> CV calcification should be assessed in all patients or only in selected cases depending on the resources available in each country&#46;<a class="elsevierStyleCrossRef" href="#bib0780"><span class="elsevierStyleSup">6</span></a> Obviously&#44; the arrival of much less expensive generic drugs could make it easier to use drugs with a better therapeutic margin without the need of strict prescreening&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Different studies have shown consistently that once vascular calcification is established it follows a progressive&#44; and likely accelerated&#44; course&#46;<a class="elsevierStyleCrossRef" href="#bib1475"><span class="elsevierStyleSup">145</span></a> Therefore from a purely academic perspective&#44; it is clear that the use of non-Ca-based P binders should be encouraged&#44; especially in patients who already have vascular calcifications and in those with low levels of PTH or alkaline phosphatase&#46; Patients with specific characteristics may also benefit from non-Ca-based P binders&#44; e&#46;g&#46; over 65 years with a reasonable life expectancy&#44;<a class="elsevierStyleCrossRefs" href="#bib0985"><span class="elsevierStyleSup">47&#44;81</span></a> diabetics&#44; treated with warfarin&#44; incident dialysis patients in whom it is anticipated a long time on the transplant waiting list&#44; young CKD patients in whom a long evolution is expected&#44; or patients with proven progression of vascular calcification&#46; Magnesium and iron deficiency should probably be avoided as well&#44; especially in these patients&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Some patients with moderate&#8211;severe secondary hyperparathyroidism should be preferentially treated with calcimimetics or low-dose VDR activators&#46;<a class="elsevierStyleCrossRefs" href="#bib0875"><span class="elsevierStyleSup">25&#44;78</span></a><span class="elsevierStyleItalic">Native</span> vitamin D or selective VDR activators could be preferentially considered in patients with vascular calcification with low serum calcium without hyperphosphataemia&#44; and native vitamin D in patients with suspected adynamic bone disease<a class="elsevierStyleCrossRefs" href="#bib1210"><span class="elsevierStyleSup">92&#44;146</span></a>&#59; in addition&#44; exposure to high Ca concentrations in the dialysate bath should be limited&#44;<a class="elsevierStyleCrossRefs" href="#bib1375"><span class="elsevierStyleSup">125&#44;147&#8211;149</span></a> including peritoneal dialysis patients&#46;<a class="elsevierStyleCrossRef" href="#bib1500"><span class="elsevierStyleSup">150</span></a> In any case&#44; the KDIGO guidelines propose an assessment of vascular calcification in <span class="elsevierStyleItalic">any</span> patient in whom awareness of its presence could influence therapeutic decision&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">As we have shown in the first part of this review&#44; we consider that initial assessment of vascular calcification should be done with unsophisticated plain X-rays&#44; and we believe that the presence of vascular calcification&#44; especially in muscular arteries such as hands arteries&#44; would emphasise the need to control Ca&#8211;P metabolism-related factors &#40;and each nephrology community would need to establish an Adragao score interval where the most expensive treatments should be implemented depending on the different finantial resources&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Finally&#44; it is known that patients who do <span class="elsevierStyleItalic">not</span> present valve or vascular calcification have a good prognosis during the following years and it is likely that the future of these patients will not be in danger if more economical medications are used&#44; should that priority be above academic considerations&#46; Nevertheless&#44; it is obvious that studies aimed to confirm these ideas&#44; as well as the recommendations related to the imaging technique used and re-analysis periodicity&#44; especially in young patients who are not candidates for kidney transplant within a reasonable period of time&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conclusions</span><p id="par0115" class="elsevierStylePara elsevierViewall">CKD patients present a very high risk of CV disease and premature death&#59; therefore we should offer them the opportunity to have the best prevention and treatment possible&#46; Unfortunately&#44; though the absolute costs are a concern&#44; quantitative or qualitative knowledge of CV calcification could help to optimise economic resources and to assign the more expensive treatments to the patients with greater expectations of improvement&#46; Therefore&#44; we believe that CV calcification should be part of future protocols and clinical studies since it is a distinguishing characteristic of CKD&#8211;MBD&#44; it is a valid predictor of clinical evolution&#44; it is modifiable&#44; and its progression seems to increase with certain treatments &#40;iatrogenic effect&#41; whereas others strategies seem to attenuate it&#46; Obviously&#44; assessing vascular calcification only makes sense if the result can be used by the nephrologist to make treatment decisions&#44; especially early decisions&#44; especially early in the course of the disease&#44; and with the possibility of following the Hippocratic principle of &#8220;first&#44; do no harm&#8221; or the more recent &#8220;prevention is better than cure&#8221;&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Key concepts</span><p id="par0120" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0125" class="elsevierStylePara elsevierViewall">CV calcification is part of CKD&#8211;MBD&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0130" class="elsevierStylePara elsevierViewall">The 2009 KDIGO guidelines &#40;and the 2015 publication of their preliminary controversies&#41; and the 2011 Spanish guidelines deem it reasonable to use information on vascular calcification to guide CKD&#8211;MBD management&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0135" class="elsevierStylePara elsevierViewall">Assessment of CV calcification should be performed in all patients&#44; or only in selected cases depending on the resources available in each health care system&#46; This is as long as the information on the absence&#47;presence&#47;degree of vascular calcification may affect treatment decisions&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0140" class="elsevierStylePara elsevierViewall">CV calcification is a potentially modifiable risk factor&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0145" class="elsevierStylePara elsevierViewall">CV calcification progression increases with certain treatments &#40;potential iatrogenic effects&#41; whereas other drugs seem to attenuate it&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0150" class="elsevierStylePara elsevierViewall">In <span class="elsevierStyleItalic">clinical</span> studies and meta-analyses&#44; non-calcium-based phosphate binders or calcimimetics seem to attenuate clinical progression of vascular calcification versus calcium-based P binders or standard treatment regimens for secondary hyperparathyroidism without calcimimetics&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0155" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Experimental</span> models demonstrate that different vitamin D compounds &#40;calcitriol vs&#46; <span class="elsevierStyleItalic">selective</span> vitamin D receptor activators&#59; e&#46;g&#46; paricalcitol&#41; have differential effects on vascular calcification&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0160" class="elsevierStylePara elsevierViewall">There is preliminary data on the influence of other drugs &#40;e&#46;g&#46; vitamin K&#44; bisphosphonates&#44; sodium thiosulfate&#44; or SNF472&#41; on vascular calcification progression in CKD patients&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0165" class="elsevierStylePara elsevierViewall">Although there is no definitive proof that personalised treatment based on the presence&#47;absence&#47;degree of vascular calcification improves survival of CKD patients&#44; a nihilistic attitude does not seem justified&#46;</p></li></ul></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Funding</span><p id="par0170" class="elsevierStylePara elsevierViewall">No funding was received to complete this work&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0175" class="elsevierStylePara elsevierViewall">Dr Jordi Bover received conference honorariums from AbbVie&#44; Amgen&#44; Genzyme&#44; and Shire&#44; as well as consultation fees from AbbVie&#44; Amgen&#44; Vifor&#47;Fresenius-Pharma&#44; Chugai&#44; Medice&#44; Genzyme&#47;Sanofi&#44; and Sanifit&#46; Dr J&#46;L&#46; G&#243;rriz received conference honorariums and grants from AbbVie&#46; Dr P&#46; Ure&#241;a received conference honorariums or consultation fees from Amgen&#44; AbbVie&#44; Genzyme-Sanofi&#44; Medice&#44; Hemotech&#44; and Fresenius&#46; Dr M&#46;J&#46; Lloret received conference honorariums from Sanofi and AbbVie&#46;</p></span></span>"
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            1 => "Vascular calcification"
            2 => "Chronic kidney disease&#8211;mineral and bone disorders"
            3 => "Phosphate"
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            0 => "Enfermedad renal cr&#243;nica"
            1 => "Calcificaci&#243;n vascular"
            2 => "<span class="elsevierStyleItalic">Chronic kidney disease-mineral and bone disorders</span>"
            3 => "Fosfato"
            4 => "Vitamina D"
            5 => "Calcimim&#233;ticos"
            6 => "Calcifilaxis"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cardiovascular &#40;CV&#41; calcification is a highly prevalent condition at all stages of chronic kidney disease &#40;CKD&#41; and is directly associated with increased CV and global morbidity and mortality&#46; In the first part of this review&#44; we have shown that CV calcifications represent an important part of the CKD&#8211;MBD complex and are a superior predictor of clinical outcomes in our patients&#46; However&#44; it is also necessary to demonstrate that CV calcification is a modifiable risk factor including the possibility of decreasing &#40;or at least not aggravating&#41; its progression with iatrogenic manoeuvres&#46; Although&#44; strictly speaking&#44; only circumstantial evidence is available&#44; it is known that certain drugs may modify the progression of CV calcifications&#44; even though a direct causal link with improved survival has not been demonstrated&#46; For example&#44; non-calcium-based phosphate binders demonstrated the ability to attenuate the progression of CV calcification compared with the liberal use of calcium-based phosphate binders in several randomised clinical trials&#46; Moreover&#44; although only in experimental conditions&#44; selective activators of the vitamin D receptor seem to have a wider therapeutic margin against CV calcification&#46; Finally&#44; calcimimetics seem to attenuate the progression of CV calcification in dialysis patients&#46; While new therapeutic strategies are being developed &#40;i&#46;e&#46; vitamin K&#44; SNF472&#44; etc&#46;&#41;&#44; we suggest that the evaluation of CV calcifications could be a diagnostic tool used by nephrologists to personalise their therapeutic decisions&#46;</p></span>"
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      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La calcificaci&#243;n cardiovascular &#40;CV&#41; es una condici&#243;n muy prevalente en todos los estadios de la enfermedad renal cr&#243;nica &#40;ERC&#41; y se asocia directamente a una mayor morbimortalidad CV y global&#46; En la primera parte de esta revisi&#243;n hemos mostrado c&#243;mo las calcificaciones CV son una caracter&#237;stica destacada del complejo CKD-MBD &#40;<span class="elsevierStyleItalic">chronic kidney disease-mineral and bone disorders</span>&#41; as&#237; como un predictor superior de la evoluci&#243;n cl&#237;nica de nuestros pacientes&#46; No obstante&#44; es necesario tambi&#233;n demostrar que la calcificaci&#243;n CV es un factor de riesgo modificable y con la posibilidad&#44; como m&#237;nimo&#44; de poder disminuir su progresi&#243;n &#40;o al menos no agravarla&#41; con maniobras iatrog&#233;nicas&#46; Aunque estrictamente solo se disponga de evidencias circunstanciales&#44; sabemos que el uso de determinados f&#225;rmacos puede modificar la progresi&#243;n de las calcificaciones CV&#44; aunque no se ha demostrado un v&#237;nculo directo causal sobre la mejor&#237;a de la supervivencia&#46; En este sentido&#44; el uso de quelantes del f&#243;sforo no c&#225;lcicos ha demostrado reducir la progresi&#243;n de las calcificaciones CV en comparaci&#243;n con el uso liberal de quelantes c&#225;lcicos en varios ensayos cl&#237;nicos aleatorizados&#46; Por otra parte&#44; aunque solo a nivel experimental&#44; los activadores selectivos del receptor de la vitamina D parecen mostrar un mayor margen terap&#233;utico contra la calcificaci&#243;n CV&#46; Finalmente&#44; los calcimim&#233;ticos tambi&#233;n parece que podr&#237;an atenuar la progresi&#243;n de la calcificaci&#243;n CV en pacientes en di&#225;lisis&#46; Mientras se desarrollan nuevas estrategias terap&#233;uticas &#40;p&#46; ej&#46; vitamina K&#44; SNF472&#8230;&#41;&#44; proponemos que la valoraci&#243;n de las calcificaciones CV puede ser una herramienta usada por el nefr&#243;logo para la toma individualizada de decisiones terap&#233;uticas&#46;</p></span>"
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    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Bover J&#44; Ure&#241;a-Torres P&#44; G&#243;rriz JL&#44; Lloret MJ&#44; da Silva I&#44; Ruiz-Garc&#237;a C&#44; et al&#46; Calcificaciones cardiovasculares en la enfermedad renal cr&#243;nica&#58; Potenciales implicaciones terap&#233;uticas&#46; Nefrologia&#46; 2016&#59;36&#58;597&#8211;608&#46;</p>"
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        "texto" => "<p id="par0180" class="elsevierStylePara elsevierViewall">Dr Jordi Bover belongs to the Red Nacional RedinRen &#91;National Kidney Research Network&#93; &#40;RD06&#47;0016&#47;0001 and RD12&#47;0021&#47;0033&#41;&#44; the Red de Biobancos Nacional Espa&#241;ola &#91;Spanish National Biobank Network&#93; &#40;RD09&#47;0076&#47;00064&#41;&#44; and to the Grupo Catal&#225;n de Investigaci&#243;n AGAUR &#91;AGAUR Catalan Research Group&#93; &#40;2009 SGR-1116&#41;&#46; He also collaborates with the Fundaci&#243;n I&#241;igo &#193;lvarez de Toledo &#40;FRIAT&#41; &#91;I&#241;igo &#193;lvarez Foundation of Toledo&#93;&#46; We also wish to thank Ricardo Pellejero for his important bibliographic help&#46;</p>"
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Article information
ISSN: 20132514
Original language: English
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Nefrología (English Edition)