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Published on: June 2, 2022
Vascular calcification in dialysis patients
1Manchester Institute of Nephrology and Transplantation, The Royal Infirmary, United Kingdom. Alastair.Hutchison@CMMC.nhs.uk
Insights
Vascular calcification in chronic kidney disease (CKD) is linked to mortality. New treatments for mineral metabolism, including phosphate binders and calcimimetics, offer improved management of hyperphosphatemia and parathyroid hormone (PTH) levels in end-stage renal disease (ESRD).
Area of Science:
- Nephrology
- Cardiovascular Medicine
- Endocrinology
Background:
- Vascular disease and mortality are linked to renal osteodystrophy in chronic kidney disease (CKD), but the pathophysiology of vascular calcification in end-stage renal disease (ESRD) remains unclear.
- Known risk factors for vascular calcification in ESRD include age, hypertension, dialysis duration, and notably, calcium and phosphate metabolism abnormalities.
- While statistical associations exist, prospective studies are needed to establish definitive cause-and-effect relationships for vascular calcification in CKD.
Purpose of the Study:
- To review the current understanding of vascular calcification in ESRD.
- To discuss the role of mineral metabolism abnormalities in CKD progression.
- To evaluate recent pharmacological advancements in managing mineral and bone disorders in CKD patients.
Main Methods:
- Review of existing literature on renal osteodystrophy, vascular disease, and mortality in CKD.
- Analysis of risk factors associated with vascular calcification in ESRD.
- Evaluation of the efficacy and safety of novel therapeutic agents like lanthanum carbonate and cinacalcet.
- Discussion of emerging evidence on the metabolic effects of vitamin D analogues.
Main Results:
- Lanthanum carbonate demonstrates efficacy and safety in managing hyperphosphatemia.
- Vitamin D analogues may offer survival advantages beyond PTH control.
- Calcimimetics provide precise PTH control but incur significant financial costs.
- These agents offer tools to investigate the complex interplay of calcium, phosphate, vitamin D, and PTH.
Conclusions:
- Effective management of mineral metabolism is crucial for patients with CKD and ESRD.
- Pharmacological advancements provide new avenues for treating vascular complications.
- Further research is essential to elucidate the precise mechanisms and optimize therapeutic strategies for CKD-related vascular disease.
Abstract:
Renal osteodystrophy, vascular disease and mortality are believed to be linked in patients with chronic kidney disease (CKD), although to date most of the evidence is based only on statistical associations. The precise pathophysiology of vascular calcification in end stagerenal disease (ESRD) is unknown, but risk factors include age, hypertension, time on dialysis, and, most significantly, abnormalities in calcium and phosphate metabolism. Prospective studies are required before 'cause and effect' can be established with certainty, but it is an active metabolic process with inhibitors and promoters. Clinical management of hyperphosphataemia is being made easier by the introduction of potent non-calcium based oral phosphate binders such as lanthanum carbonate. Short and long term studies have demonstrated its efficacy and safety. Vitamin D analogues have been a disappointment as far as control of serum parathyroid hormone (PTH) levels, but evidence is emerging that vitamin D has other important metabolic effects apart from this, and may confer survival advantages to patients with CKD. Calcimimetics such as cinacalcet enable much more effective and precise control of PTH levels, but at the price of major financial burden. Whilst it is unreasonable to expect that any one of these recent pharmacological developments will be a panacea, they provide researchers with the tools to begin to examine the complex interplay between calcium, phosphate, vitamin D and PTH such that further progress is fortunately inevitable.
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