Calcimimetics in chronic kidney disease: evidence, opportunities and challenges

Secondary hyperparathyroidism (SHPT) remains a highly prevalent and important complication in patients with chronic kidney disease (CKD). Indeed, SHPT may compromise bone health and contribute to the increased cardiovascular risks of these patients. Calcimimetic agents may help to control SHPT and to achieve the stringent mineral metabolism targets in patients with CKD stage 5D. Whether this will translate in improved patient-level outcomes remains to be demonstrated in adequately powered prospective intervention studies. These studies are currently ongoing. Additional investigations are required to define how calcimimetics fit best in the expanding armamentarium to treat SHPT. The role of vitamin D (analogs) and parathyroidectomy needs to be reevaluated in the calcimimetic era. Persistent hyperparathyroidism after successful renal transplantation may also become an important indication for therapy with calcimimetics. In patients with this complication, calcimimetics may help to improve bone health both by suppressing bone turnover and demineralization and may retard or prevent nephrocalcinosis of the graft. The evidence for using calcimimetics in CKD patients not yet on dialysis, conversely, is less straightforward. In these patients, therapy for SHPT should rather be focused on the primary trigger, i.e. the high phosphate load relative to the functional nephron mass.