1. ³Emergency Medicine Department of Istria, Umag, Croatia
EFFECT OF CALCITRIOL AND PARICALCITOL ON SERUM PARATHYROID HORMONE LEVELS AND MINERAL METABOLISM DISORDER IN PATIENTS ON MAINTENANCE HEMODIALYSIS
Ljušaj M¹, Livajić M¹, Kuzmanović L¹, Vidić Ž², Šiljegović S², Kalinić N², Dorčić G³, Devčić B², Rački S², Vujičić B²
¹Undergraduate study of Medicine, Faculty of Medicine, University of Rijeka, Rijeka, Croatia
²Department of Nephrology, Dialysis and Kidney Transplantation, Clinic of Internal Medicine, Clinical Hospital Centre Rijeka, Rijeka, Croatia
³Emergency Medicine Department of Istria, Umag, Croatia
Rijeka,2015.

2. Contents Introduction Hypothesis Aim Patients Methods Results
Conclusion

3. KIDNEY FUNCTION Blood filtration Regulation of electrolytes
Production of urine
Blood pressure
Acid-bace balanse
Production of hormones
- calcitriol
- erythropoietin
- renin
Vrhovac B, Jakšić B, Reiner Ž, Vucelić B , ur. Interna medicina. Zagreb: Naklada Ljevak, 2008.

4. CHRONIC KIDNEY DISEASE- CKD
Progressive loss in renal function

5. PARATHYROID HORMONE AND MINERAL METABOLISM
Guyton A, Hall J, Medicinska fiziologija. Zagreb: Medicinska naklada, 2012.

6. CHRONIC KIDNEY DISEASE – MINERAL BONE DISORDER (CKD-MBD)
systemic disorder of mineral and bone metabolism due to CKD
manifested by:
abnormalities of calcium, phosporus, parathyroid hormone (PTH) or vitamin D metabolism
abnormalities in bone turnover, mineralisation, volume linear growth, or strenght
extraskeletal calcification
Hyperphosphatemia, hyperparathyroidism
and hypercalcemia all have potential
roles in the pathogenesis of vascular
calcification
Management of secondary hyperparathyroidism and mineral metabolism abnormalities in dialysis patients, L Darryl Quarles, MD Michael Berkoben, MD: Overview of chronic kidney disease-mineral bone disorder (CKD-MBD), Wajeh Y Qunibi, MD, William L Henrich , MD, MACP

7. SECONDARY HYPERPARATHYROIDISM
begins early in the course of CKD
occurs in response of:
phosphate retention
decreased calcium concretration
Decreased 1,25-dihydroxyvitamin D concentration
increased fibroblast
growth factor 23 (FGF-23) concentration
Overview of chronic kidney disease-mineral bone disorder (CKD-MBD), Wajeh Y Qunibi, MD, William L Henrich , MD, MACP

8. THE MANAGEMENT OF SECONDARY HYPERPARATHYROIDISM IN DIALYSIS PATIENTS
Phosphate binders
Calcitriol or vitamin D analogs
Calcimimetics
Management of secondary hyperparathyroidism and mineral metabolism abnormalities in dialysis patients, L Darryl Quarles, MD Michael Berkoben, MD

9. CALCITRIOL AND PARICALCITOL
( 1-25-dihydroxycholecalciferol)
active metabolite of vitamin D
Paricalcitol
19-nor-1,25-(OH)2 
Analog of 1,25-dihydroxyergocalciferol, the active form of vitamin D2
Darryl Quarles L, Berkoben M, Managment of secondary hyperparathyroidism and mineral metabolism abnormalities in dialysis patients. UpToDate, :49:10

10. To compare the efficacy of calcitriol and paricalcitol on the reduction of serum PTH levels, and incidence of hypercalcaemia and hyperphosphatemia

11. AIM Analyze demographic data of patients
Statistical analysis of results of the study
Potential clinical application of our results

12. PATIENTS
63 hemodialysis patients in Department of Nephrology,Dialysis and Kidney Transplantation, Clinical Hospital Centre Rijeka
Age 67.3, 53 % male
Treatment with calcitriol or paricalcitol in the period from January 1, 2014, to December 31, 2014.
No statistically significant difference in demographic and laboratory parameters between groups at the baseline
Screened for eligibility (n=63)
Included with signed informed consent (n=58)
Analysed at the follow up 55
Calcitriol group (n=26)
Paricalcitol group (n=28)

13. EXCLUSION CRITERIA Patients younger than 18 Unsigned informed consent
Pregnancy and lactation
Clinical and laboratory signs of systemic inflammation
Malignant disease in treatment, non-treatable or with a recidive in last 2 years
Termination of HD treatment and vitamin D analogue treatment for any reason before the follow up after six months

14. METHODS
We examined serum levels of PTH, Ca and P at the baseline, and after 6 months
Hypercalcemia was defined as serum Ca>2.37 mmol/L
Hyperphosphatemia was defined as serum P>1.78 mmol/L
Am J Kidney Dis May;55(5): doi: /j.ajkd Epub 2010 Apr 3. KDOQI US commentary on the 2009 KDIGO Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of CKD-Mineral and Bone Disorder (CKD-MBD). Uhlig K1, Berns JS, Kestenbaum B, Kumar R, Leonard MB, Martin KJ, Sprague SM, Goldfarb S.

15. RESULTS Table 1. Baseline characteristics of patients (mean±SD)
Calcitriol group N(%)=26(47)
Paricalcitol group N(%)=28(58) p
Age (yrs)
71,78 ± 12,72
67,23 ± 12,16
0,05
Dialysis duration (months)
51,14 ± 67,96
53,94 ± 59,94
0,85
Male:Female (%)
12 (42):14 (58)
13(47):15(53)
Etiology of ESRD [n(%)]:
Diabetic nephropathy
6 (23)
13 (45) -
Glomerulonephritis
4 (17)
1 (5)
Hypertensive nephropathy
11 (42)
7 (23)
Interstitial nephritis
2 (7)
4 (14)
Polycystic kidney disease
2 (8)
Other
1 (4)
RRF (ml)
364,28 ± 465,24
321,05 ± 370,46
0,67
Barthel score
17,14 ± 2,99
16,86 ± 3,31
0,73
Davies score
0,82 ± 0,47
0,89 ± 0,64
0,61
Erythrocites
3,59 ± 0,43
3,64 ± 0,41
0,63
Leukocites
7,04 ± 2,15
6,56 ± 1,52
0,30
Haemoglobin [g/L]
104,03 ± 12,96
107,57 ± 12,04
0,25
Albumin [g/L]
37,16 ± 4,75
39,61 ± 3,66
<0,05
CRP [g/L]
11,01 ± 13,75
8,56 ± 11,66
0,43
Glucose [g/L]
6,91 ± 6,47
8,88 ± 4,99
0,16
Urea [mmol/L]
22,06 ± 5,52
20,32 ± 4,62
Chreatinine [umol/L]
682,2 ± 221,64
706,23 ± 196,68
0,64
Kt/V
1,23 ± 0,25
1,33 ± 0,3
0,18
PTH [pmol/L]
57.66±54.33
41.76±25,27
0,78
Ca [mmol/L]
2,13 ± 0,17
2,26 ± 0,11
P [mmol/L]
1,49 ± 0,5
1,44 ± 0,36

16. RESULTS
No significant difference in PTH serum levels in the group treated with calcitriol (57.66±54.33 vs. 53.5±32.88; P=0.405), and the group treated with paricalcitol (41.76±25,27 vs ±23.55; P=0.127), after 6 months
There was significantly higher percentage of patients with hypercalcemia in the group treated with calcitriol, after 6 months (0% vs. 23%; P=0.030)
The percentage of patients with hyperphosphatemia changed, but not significantly, in both groups after 6 months: paricalcitol group (0% vs. 10%; P=0.309), and calcitriol group (11% vs. 21%; P=0.496)

17. CONCLUSIONS
Calcitriol and paricalcitol are equally efficient in reduction of serum PTH levels in the patients on the maintenance HD, after 6 months
patients treated with calcitriol had significantly higher incidence of hypercalcemia
Further studies on bigger number of patients are required to see the survival benefits of paricalcitol over the calcitriol

18. Contact us: Merljinda Ljušaj merljinda.ljusaj@gmail.com
Lara Kuzmanović
Marija Livajić