Bajo MA, Possante C, Jimenez C, Sanches S, Aguilera A, Selgas
R
Frequent relapse of secondary hyperparathyroidism after oral
pulse calcitriol administration in peritoneal dialysis patients
17th Annual CAPD Conference
Perit Dial Int Suppl 1
(Feb) 17:S47 1997
Despite the widespread use of vitamin D analogues hyperparathyroidism
remains a frequent occurrence in dialysis patients. Intravenous
pulse therapy has been shown to be effective in hemodialysis patients
and oral pulse therapy works similarly in CAPD. Published papers
have not usually reported on relapse rates.
This abstract reports on the effects of treatment with oral pulse
therapy (4 - 8 micrograms weekly in 2 doses) in 15 patients, followed
by the results of withdrawal of treatment. Treatment lasted from 22 to 225
days.
Target iPTH was 150 - 300 pg/ml, and pulse therapy was converted to
daily low dose therapy once patients achieved this (n = 8), or if
they became hypercalcaemic (n = 6). 1 patient was transplanted.
Overall mean iPTH fell from 559 to 196 pg/ml. One month after
cessation of therapy or changing to small daily doses, iPTH rebounded
to a mean of 430 pg/ml. The authors conclude that although oral
pulse calcitriol therapy is effective, its withdrawal is frequently
associated with relapse.
Comment: Pulse therapy was designed to minimise hypercalcaemia, so
conversion to daily low dose therapy in patients
who become hypercalcaemic does not seem logical. They should have
probably continued pulse therapy, but at a lower dose, with or
without a reduction in the dialysis fluid calcium level. Once the
desired range of iPTH is reached, one must consolidate the therapy
with strict phosphate control and maintain free (ionized) calcium at
the top end of the normal range. If iPTH does rebound then restart
the pulse therapy. The abstract would be enhanced by more detail
about the patients' phosphate control, since it is well known that
this is an important factor in control of iPTH levels.
Non-parametric data (iPTH and dose of aluminum) is repeatedly quoted
incorrectly as mean & SD rather than geometric mean & range.
However, this work emphasises the point that oral pulse calcitriol is an
effective treatment for high iPTH levels in many patients (in this
study, 8/14), but it is not a "once and for all" cure.
(Alastair J. Hutchinson, M.D., The Royal Infirmary, Manchester, UK)
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17th Annual CAPD Conference
CRF by problem area :
Bone disease/aluminum