Vitamin D receptor activation and survival in chronic kidney disease.
Replacement of activated vitamin D has been the cornerstone of therapy for secondary hyperparathyroidism (SHPT). Recent findings from several large observational studies have suggested that the benefits of vitamin D receptor activators (VDRA) may extend beyond the traditional parathyroid hormone (PTH)-lowering effect, and could result in direct cardiovascular and metabolic benefits. The advent of several new analogs of the activated vitamin D molecule has widened our therapeutic armamentarium, but has also made therapeutic decisions more complicated. Treatment of SHPT has become even more complex with the arrival of the first calcium-sensing receptor (CSR) agonist (cinacalcet hydrochloride) and with the uncovering of novel mechanisms responsible for SHPT. We provide a brief overview of the physiology and pathophysiology of SHPT, with a focus on vitamin D metabolism, and discuss various practical aspects of VDRA therapy and its reported association with survival in recent observational studies. A detailed discussion of the available agents is aimed at providing the practicing physician with a clear understanding of the advantages or disadvantages of the individual medications. A number of open questions are also analyzed, including the present and future roles of CSR agonists and 25(OH) vitamin D replacement.
Kovesdy
C P
CP
Division of Nephrology, Salem Veterans Affairs Medical Center, Salem, Virginia 24153, USA. csaba.kovesdy@va.gov
Kalantar-Zadeh
K
K
D002908:Chronic Disease; D006801:Humans; D006962:Hyperparathyroidism, Secondary / Q000188:drug therapy* / Q000209:etiology / Q000378:metabolism; D007674:Kidney Diseases / Q000150:complications / Q000401:mortality*; D010281:Parathyroid Hormone / Q000097:blood / Q000378:metabolism; D018167:Receptors, Calcitriol / Q000819:agonists*; D014807:Vitamin D / Q000031:analogs & derivatives* / Q000494:pharmacology / Q000627:therapeutic use*
D010281:Parathyroid Hormone; D018167:Receptors, Calcitriol; D014807:Vitamin D