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Vitamin D compounds for people with chronic kidney disease not requiring dialysis
Suetonia C Palmer1, David O McGregor, Jonathan C Craig
1Renal Division, Brigham and Women's Hospital, Harvard Medical School, Harvard Institute of Medicine, Room 550, 4 Blackfan Street, Boston, MA, USA, 02115.
Insights
Vitamin D therapy effectively lowers parathyroid hormone (PTH) in chronic kidney disease (CKD) patients not on dialysis. However, its impact on mortality and cardiovascular outcomes requires further investigation, with potential increases in phosphorus and calcium levels noted.
Area of Science:
- Nephrology
- Endocrinology
- Pharmacology
Background:
- Vitamin D compounds are crucial for managing elevated serum parathyroid hormone (PTH) in chronic kidney disease (CKD).
- This review focuses on non-dialysis CKD patients, assessing vitamin D's efficacy beyond PTH suppression.
Purpose of the Study:
- To evaluate vitamin D therapy's effectiveness on biochemical, bone, cardiovascular, and mortality outcomes in non-dialysis CKD patients.
- To compare different vitamin D formulations, schedules, and administration routes.
Main Methods:
- Systematic review and meta-analysis of randomized controlled trials (RCTs).
- Searched major databases including Cochrane Renal Group, CENTRAL, MEDLINE, and EMBASE.
- Included studies compared established and newer vitamin D compounds in non-dialysis CKD patients.
Main Results:
- Sixteen RCTs involving 894 patients were analyzed.
- Vitamin D significantly reduced serum PTH levels but did not alter mortality or dialysis initiation.
- Treatment led to increased serum phosphorus and calcium levels.
Conclusions:
- Insufficient data exist to determine vitamin D's effect on mortality and cardiovascular outcomes in this population.
- While vitamin D lowers PTH, the clinical benefits versus risks of elevated phosphorus and calcium remain unclear.
Background:
Vitamin D compounds are used to suppress elevated serum parathyroid hormone (PTH) in people with chronic kidney disease (CKD).
Objectives:
To assess the efficacy of vitamin D therapy on biochemical, bone, cardiovascular, and mortality outcomes in people with CKD and not requiring dialysis.
Search Strategy:
We searched The Cochrane Renal Group's specialised register, Cochrane's Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and reference lists of retrieved articles.
Selection Criteria:
Randomised controlled trials (RCTs) comparing different forms, schedules, or routes of administration of vitamin D compounds for people with CKD not requiring dialysis were included. Vitamin D compounds were defined as established (calcitriol, alfacalcidol, 24,25(OH)(2)vitamin D(3)) or newer (doxercalciferol, maxacalcitol, paricalcitol, falecalcitriol) vitamin D compounds.
Data Collection And Analysis:
Data were extracted by two authors. Statistical analyses were performed using the random effects model. Results were summarized as risk ratio (RR) for dichotomous outcomes or mean differences (MD) for continuous outcomes with 95% confidence intervals (CI).
Main Results:
Sixteen studies (894 patients) were included. No formulation, route, or schedule of vitamin D compound was found to alter the mortality risk or need for dialysis. Vitamin D compounds significantly lowered serum PTH (4 studies, 153 patients: MD -49.34 pg/mL, 95% CI -85.70 to -12.97 (-5.6 pmol/L, 95% CI -9.77 to -1.48)) and were more likely to reduce serum PTH > 30% from baseline value (264 patients: RR 7.87, 95% CI 4.87 to 12.73). Vitamin D treatment was associated with increased end of treatment serum phosphorus (3 studies, 140 patients: MD 0.37 mg/dL, 95% CI 0.09, 0.66 (0.12 mmol/L, 95% CI 0.03, 0.21)) and serum calcium (5 studies, 184 patients: MD 0.20 mg/dL, 95% CI 0.17 to 0.23 (0.05 mmol/L, 95% CI 0.04 to 0.06)). Few data were available comparing intermittent with daily vitamin D administration, or other schedules of dosing.
Authors' Conclusions:
There are not sufficient data to determine the effect of vitamin D compounds on mortality and cardiovascular outcomes in people with CKD not requiring dialysis. While vitamin D compounds reduce serum PTH (49.3 pg/mL (5.6 pmol/L)) compared with placebo, the relative clinical benefits of PTH lowering versus treatment-related increases in serum phosphorus and calcium remain to be understood.
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