EFFECT OF CINACALCET CESSATION ON PARATHRYROIDECTOMY AND BIOCHEMICAL MARKERS IN CHRONIC KIDNEY DISEASE PATIENTS FROM TOPEND OF THE NORTHERN TERRITORY

V KAREPALLI1,  A ABEYARATNE1, M MOGULLA1, K PRIYADARSHANA1
1Royal Darwin Hospital, Nightcliff, Australia

Aim: To evaluate the effect of Cinacalcet cessation on biochemical markers and rates of Parathyroidectomy in Topend of Northern Territory.
Background: Secondary hyperparathyroidism is a well-known complication in Chronic Kidney Disease. Hyperparathyroidism is associated with bone pain, fractures, vascular calcification and increased cardiovascular risk. According to the EVOLVE study, Cinacalcet did not show benefit in reducing the cardiovascular mortality but significantly reduced the requirement for Parathyroidectomy. Due to the limited resources, number of Parathyroidectomies performed in Northern Territory is lower compared to rest of the Australia. Since Cinacalcet was PBS-delisted in August 2015 Parathyroidectomy became the only treatment option available. In Northern Territory Parathyroidectomies are performed only at Royal Darwin Hospital.
Methods: We collected retrospective data from electronic records on Parathyroidectomies (n =19) performed in Royal Darwin Hospital between 2012 and 2018. We included the total number of patients on Cinacalcet (n=42) before August 2015 and excluded the paediatric population. We conducted standard t-test to analyse the difference in biochemical parameters with effect to Cinacalcet.
Results: The number of Parathyroidectomies increased from two per year to four per year post cessation of Cinacalcet. Nearly half of these patients were on Cinaclacet until it was PBS-delisted. Mean PTH levels increased from 140.8 pmol/l to 176.4 pmol/l and mean Calcium levels increased from 2.27 mmol/l to 2.34 mmol/l, whereas mean phosphate levels were decreased from 1.75 mmol/l to 1.41 mmol/l.
Conclusions: Cinacalcet cessation led to increase in PTH levels and the number of parathyroidectomies in Northern Territory. We need further analysis into risk of fractures in association with Cinacalcet cessation and cost analysis to postulate the advantage.


Biography:
First year Renal Advance Trainee at Royal Darwin Hospital.

EFFECT OF ORAL HYGIENE ON ESA RESISTANCE INDEX IN HEMODIALYSIS PATIENTS DR SARDJITO, YOGYAKARTA

SY WIBISONO1
1Rsud Ketapang, Ketapang, Indonesia

Background. Erythropoietin (ESA) resistance are common in patients who undergo regular hemodialysis, and most of them caused by the inflammatory process. Poor in oral hygiene is one source of inflammation in patients undergoing regular hemodialysis. The purpose of this study was to assess the effect of oral hygiene to ESA resistance index in patients undergoing regular hemodialysis.
Method.The study was conducted in hemodialysis care unit teaching hospital in Yogyakarta. Cross sectional study design, involving routine hemodialysis patients. Methode of collecting sample by consecutive sampling. Statistical test used is regression analysis correlation. ESA resistance index (ERI) is defined as weekly ESA dose (U/kg/week) divided hemoglobin level (g/dl).
Results. The 109 patients included in the study, with good oral hygiene index of 58 people (53%), moderate 40 (37%) and poororal hygiene 10 people (10%). Number of patients with ERI<5 are 62 (56.8%), 5-15 are 43 people (39.4%) and> 15 as many as 4 people (3.7%). Results of regression test showed significance with p <0.05
Conclusion. This study shows the influence of oral hygiene to ESA resistance index.
Keywords: oral hygiene; ESA resistance index; Inflammation


Biography:
Fellow In Nephrology And Hypertension.
Gadjah Mada University
Yogyakarta, Indonesia

FIBROBLAST GROWTH FACTOR 23 AS PREDICTOR OF ABDOMINAL AORTIC CALCIFICATION IN CHRONIC KIDNEY DISEASE PATIENTS WITH REGULAR HEMODIALYSIS: A SINGLE CENTER STUDY

RA MUZASTI1,2, N LUBIS2,  HR LUBIS1
1University of Sumatera Utara, Medan, Indonesia, 2Adam Malik Hospital, Medan, Indonesia

Background: Fibroblast growth factor 23 (FGF23) is an important hormone in the regulation of phosphate metabolism.The relationship between FGF23 and vascular calcification is still controversial. It is unclear whether FGF23 is a stimulator or inhibitor to abdominal aortic calcification (AAC) in chronic kidney disease (CKD) patients with regular hemodialysis.
Aim: To investigate the relationship between FGF23 and AAC in regular hemodialysis patients.
Method: Seventy-five regular hemodialysis patients were enrolled in this cross-sectional study. Serum levels of intact FGF23 was determined using an enzyme-linked immunosorbent assay (ELISA) and AAC was detected with lateral lumbal X-ray. The risk factors for AAC were evaluated using a logistic regression model.
Result: Of 75 patients, 51 (68.0%) had AAC. Median (min-max) intact serum FGF23 was 328 (217-950) pg/ml. Serum FGF23 levels of patients with AAC were significantly higher than those without AAC (p<0.001). Age at initiation of hemodialysis, and FGF23 levels were independent risk factors for AAC. Receiver-operating characteristic curves showed that the sensitivity and specificity of FGF23 for diagnosing AAC were 94.0% and 84.0%, respectively, with area of under the curve was 0.959 (p<0.001).
Conclusion: Elevated serum FGF23 concentrations are independently predicts AAC in CKD patients with regular hemodialysis. Further studies are needed to elucidate the potential biological mechanisms by which FGF23 may be involved in the pathogenesis of AAC.


Biography:
Fellow of Nephrology and Hypertension. Internist, 2011. Lecturer
in Division of Nephrology-Hypertension, Department of Internal Medicine, College of Medicine, Sumatera Utara University. Staff in Adam Malik Hospital, Medan.

ASSOCIATION OF BRAIN NATRIURETIC PEPTIDE (BNP) WITH KIDNEY FUNCTION DECLINE AND RISK OF LONG-TERM CHRONIC KIDNEY DISEASE (CKD)-RELATED OUTCOMES IN ELDERLY WOMEN

A KRISHNAN1, J LEWIS2, G WONG4,5,6,7, R PRINCE1,3, W LIM1,7
1Sir Charles Gairdner Hospital, Perth, Australia, 2Edith Cowan University, Perth, Australia, 3University of Western Australia, Perth, Australia, 4Centre for Renal and Transplant Research, Westmead Hospital, Sydney, Australia, 5Centre for Kidney Research at the Children’s Hospital at Westmead, Sydney, Australia, 6Sydney School of Public Health, University of Sydney, Sydney, Australia, 7Australia and New Zealand Dialysis and Transplant Registry, , Australia

Aim: To examine the associations between BNP, long-term change in kidney function and 10-year risk of CKD-related events (hospitalisations and/or mortality) in older Caucasian women.
Background: BNP is a cardiac biomarker which has been shown to be predictive for cardiovascular and all-cause mortality in the general population and in patients with CKD. One recent study suggests that BNP may predict kidney function decline, possibly related to effect of abnormal cardiac remodelling/pressure on kidney perfusion. However, the association between BNP, kidney function decline and development of CKD-related events remains unknown.
Methods: This is a population cohort study of 840 women aged ≥70 years. The associations between log-transformed BNP (logBNP), 10-year change in estimated glomerular filtration rate (eGFR, with repeated measures at baseline, 5 and 10-years) and 10-year risk of CKD-related events were assessed using linear mixed model and Cox regression analysis, respectively.
Results: Over a follow-up period of 10 years, there were 79 CKD-related events. The mean decline of eGFR over 10-years was -0.26ml/min/1.73m2/year (95%CI         -0.36, -0.15; p<0.001) for every SD increase in logBNP, adjusted for age, comorbid conditions and prevalent atherosclerotic vascular disease. In the multivariate model for CKD-related events, the adjusted hazard ratio (HR) for every SD increase in logBNP was 1.51 (95%CI 1.17, 1.95; p<0.001), adjusted for Framingham risk scores, age and baseline eGFR. In the sensitivity analyses excluding women with prevalent atherosclerotic-vascular or kidney disease (n=116), the estimates between BNP and CKD-related events remained unchanged.
Conclusion: Elevated levels of BNP were associated with a more rapid decline in eGFR and increased risk of long-term CKD-related events in older women, independent of traditional vascular risk factors and baseline kidney function.


Biography:
Anoushka completed her advanced training in nephrology this year, having done two years in Perth followed by a year in Vancouver, Canada. She has a keen interest in transplantation and CKD.

CLINICAL OUTCOMES OF HOME HAEMODIALYSIS WITH LOW DIALYSATE VOLUME

J GAUTIER1, L HIGNELL3, H JONES1, E WEINHANDL2
1NxStage Medical Inc, Lawrence, United States, 2University of Minnesota, College of Pharmacy, Minneapolis, United States, 3NxStage Medical UK Ltd, Amersham, United Kingdom

Purpose: In Australia, 13% of haemodialysis patients dialyze at home, almost always with traditional equipment. Kidney Health Australia recommends “home dialysis first” but utilization of home haemodialysis (HHD) is not increasing. We evaluated outcomes on HHD with a flexible device that is designed for patient use and employs low dialysate volume (LDV).
Methods: We collected data from HHD patients at 9 centers in western Europe. We recorded haemodialysis prescription, biochemical, and medication data at HHD initiation, and at 6 and 12 months thereafter.
Results: The cohort comprised 182 patients. Ranges of age, body mass index, and Charlson score were 15-84 years, 13.3-50.8 kg/m2, and 2-11 points, respectively. Mean training duration was 18.9 sessions. Most (93.4%) patients were prescribed 5 or 6 sessions/week, and session duration was commonly 2.0-3.5 hours; mean dialysate volume was 23.9 L/session. Mean ultrafiltration (UFR) rate declined from 6.9 to 6.6 mL/hour/kg between HHD initiation and 12 months, with a halving of patients with UFR ≥10 mL/hour/kg. Mean standardized Kt/V was 2.6 at all times; the majority of patients had standardized Kt/V between 2.4 and 3.0 at 12 months. Serum concentrations of bicarbonate, potassium, calcium, phosphorus, albumin, and hemoglobin were stable. The percentage of patients using no antihypertensive medications steadily increased from 27% at HHD initiation to 36% at 6 months and 42% at 12 months. After 36 months, 39% of patients remained on HHD, 31% had received a kidney transplant, and only 10% had died.
Conclusions: HHD with LDV is viable for a wide range of patients. Increased treatment frequency with more than 12 dialysis hours/week, low ultrafiltration intensity, stable biochemistry, reduced medication use, and good clinical outcomes are observed.


 

RET-He CORRELATED WITH IRON AND TRANSFERRIN SATURATION IN ROUTINE HEMODIALYSIS

M RUDIANSYAH1,5,R ROESLI2, A MARTAKUSUMAH2, R SUPRIYADI2, D RACHMADI3, R BANDIARA2, L LUBIS4
1Division of Nephrology & Hypertension, Department of Internal Medicine  Faculty of Medicine University of Lambung Mangkurat / Ulin General Hospital, Banjarmasin, Indonesia, 2Division of Nephrology & Hypertension, Department of Internal Medicine Faculty of Medicine University of Padjadjaran / Hasan Sadikin Hospital,  Bandung, Indonesia, 3Division of Nephrology and Hypertension, Department of Paediatrics Faculty of Medicine University of Padjadjaran / Hasan Sadikin Hospital, Bandung, Indonesia, 4Department of Anatomy, Physiology, and Cell Biology Faculty of Medicine University of Padjadjaran, Bandung, Indonesia, 5Doctoral Program, Medical Science Faculty of Medicine University of Padjadjaran , Bandung, Indonesia

Aim: to determine the correlation between RET-He and iron levels and transferrin saturation in chronic kidney disease (CKD) patients undergoing routine hemodialysis (CKD-5D).
Background: RET-He is more stable substance, and is not influenced by acute and chronic conditions. A correlation between RET-He as a new and easy parameter and iron levels and transferrin saturation in patients with CKD-5D is required.
Method: This is a cross-sectional study carried out in Hemodialysis Unit of Hasan Sadikin General Hospital Bandung..
Result: There were 181 patients with CKD-5D, 137 patients had complete data and 97 patients who fulfilled inclusion and exclusion criteria taken randomly as study subjects. Characteristics: mean of age 48+13 years, male 53 (54.6%), median of HD vintage 36 (12-168) months, hemoglobin 9.1 (4,7–13,7) gr/dL, serum iron (SI) 54 (14–166) µg/dL, total iron binding capacity (TIBC) 234 (137–429) µg/dL, Trasnferin saturation (TSat) 22.2 (10,1–75,1)% and RET-He 31.7 (19.3–37.5) pg/cell. RET-He correlated with SI (r=0.348, p<0,001) and TSat (r=0.454, p<0,001).
Conclusions: There is significant correlation between SI and Tsat levels with RET-He in CKD-5D patients.
Key words : CKD-5D, Anemia, Iron deficiency, RET-He, Transferin Saturation


Biography:
I am a lecturer in Division of Nephrology and Hypertension, Department of Internal Medicine Faculty of Medicine University of Lambung Mangkurat Banjarmasin / Ulin General Hospital Banjarmasin. I am still study at Doctoral Program, Medical Science Faculty of Medicine University of Padjadjaran Bandung. I interested about anemia, CKD MBD to investigate about how to prevent the complication likely with a traditional medicine ( Eurycoma Longifolia) and inflammation.

LONGITUDINAL CHANGES IN BONE AND MINERAL METABOLISM AFTER CESSATION OF CINACALCET IN DIALYSIS PATIENTS WITH SECONDARY HYPERPARATHYROIDISM

I RUDERMAN1,2, E SMITH1,2, N TOUSSAINT1,2,T HEWITSON1,2, S HOLT1,2
1The Royal Melbourne Hospital, Parkville, Australia, 2The University of Melbourne, Parkville, Australia

Aim: To assess changes in novel biochemical biomarkers, calciprotein particles following cessation of cinacalcet in dialysis patients.
Background: The calcimimetic agent cinacalcet is effective for the management of secondary hyperparathyroidism (SHPT) in dialysis patients. Changes to reimbursement of cinacalcet in Australia provided an opportunity to assess effects of medication cessation on biochemical and clinical outcomes in dialysis patients, including changes to novel biomarkers such as calciprotein particles (CPP). CPP are nanoparticles of mineral and protein in the circulation associated with increased vascular calcification in patients with CKD.
Methods: Dialysis patients from a single center who ceased cinacalcet between August 2015 and March 2016 were included in a prospective observational study. Blood tests were taken at time of cessation and at 1, 6 and 12 months. Clinical and biochemical outcomes were compared with an age- and gender-matched cohort of cinacalcet-naïve dialysis patients.
Results: 62 patients participated in the study. Mean age was 69.6 ± 13.2 years. Biochemical changes over 12 months following cessation of cinacalcet included an increase in serum parathyroid hormone (PTH) (42.2 [IQR 27.8-94.6] pmol/L to 114.8 [83.9-159.1] pmol/L [p<0.001]), serum calcium (2.31±0.21mmol/L to 2.46±0.14mmol/L [p<0.001]) and primary CPP (CPP-I) (p=0.002). Changes in CPP were associated with an increase in PTH (p=0.007), calcium (p=0.002) and ferritin (p=0.02) but a reduction in serum albumin (p=0.001). Over the 12-month period, there were two fractures, five cardiovascular events, one episode of calciphylaxis, and one parathyroidectomy, with a mortality rate of 19% (n=13).
Conclusion: Uniquely we report the effects of cinacalcet withdrawal in a real world setting with demonstrated increases in PTH, serum calcium and the novel prognostic marker CPP over a 12-month period.


Biography:
Irene Ruderman is a Nephrology Fellow at The Royal Melbourne Hospital. She is currently completing a PhD and is in her second year of study. Her interest is in vascular calcification and CKD-MBD

RETROSPECTIVE OBSERVATIONAL STUDY COMPARING TWO ANAEMIA MANAGEMENT PROTOCOLS FOR PATIENTS ON MAINTENANCE HAEMODIALYSIS

P LEUNG1, D LANGSFORD1, 2

1Department of Nephrology, Northern Health, Melbourne, Victoria; 2University of Melbourne, Melbourne

Aim: To determine whether a new protocol results in improved iron stores, haemoglobin stability and reduced erythropoietin-stimulating agents (ESA) use.

Background: It is recognised that haemodialysis patients require iron replacement in conjunction with ESA to manage anaemia. However, the balance of iron replacement and ESA dosing is not well described. We describe the impact of an iron protocol using transferrin saturation (TSAT) to evaluate iron repletion and ferritin to assess iron overload. Previously we used iron dosing based on gender, haemoglobin (Hb) and ferritin alone. We hypothesised this would result in increased use of iron, reduced use of ESA and improved Hb stability.

Methods: A retrospective observational study of 59 chronic haemodialysis patients (26 female, mean age 70.6) was conducted. Hb, TSAT, ferritin, iron and ESA doses were collected for six months before and after the protocol change on 1 December 2015. ESA dosing was physician determined.

Results: The mean iron dose/patient increased over 6 months (644mg v.981mg; p<0.001). The mean ferritin was 293μg/L at pre-3-6 months and 422μg/L at post-3-6 months (p<0.001). There was no significant change in TSAT (21.6% v. 22.9%; p=0.162). The mean Hb over the pre-6 months was 109.1±14.2g/L, then 110.6 ±14.5g/L at month 4 post (p=0.253), 111.7±14.3g/L at month 5 (p=0.052) and 112.7±14.5g/L at month 6 (p=0.008). The mean darbepoietin dose over pre- 6 months was 109μg per month/patient and reduced to 108μg at month 4 post, 95μg month 5 and 92μg month 6 (not statistically significant). The cost saving was $46.83 per month/person.

Conclusions: Increased iron replacement is associated with significant Hb and ferritin elevations, reduced ESA and reduced overall cost of managing anaemia in haemodialysis patients.

MARKED REDUCTION IN USE BUT MINIMAL IMPACT FOLLOWING PBS DELISTING OF CINACALCET IN A TERTIARY INSTITUTION

YS RAJARAM1, H DIXON 2, C MCBRIDE3, H GOCK1, 3

1Department of Nephrology; 2Pharmacy Department; 3Department of Medicine, University of Melbourne, St Vincent’s Hospital Melbourne, AUSTRALIA.

Background: Cinacalcet, a patented calcimimetic was PBS-listed 2008-2015 to treat secondary hyperparathyroidism (hPTH) in stage-5D CKD and reputed to improve surrogate biochemical markers of mortality and parathyroidectomy. It was PBS-delisted after the EVOLVE study demonstrated no survival benefit.

Aim: To assess at our centre: (1) Cinacalcet usage before and during PBS-listing and after PBS-de-listing, (2) Biochemical outcomes of patients that initially remained on Cinacalcet post-PBS-delisting,    (3) hPTH parathyroidectomy rate after PBS-delisting.

Methods: Pharmacy records were used to identify patients on Cinacalcet (2006-16).  From the date of PBS-delisting (Aug 1st, 2015), serum Calcium, Phosphate and PTH level were obtained from hospital records.  If Cinacalcet was later ceased, the same parameters were reviewed 3 months post-cessation.  We also identified the annual number of hPTH parathyroidectomy between 2006-2016 to calculate the parathyroidectomy rate [no. of hPTH parathyroidectomy/total dialysis patients] x 100.

Results: The number of patients prescribed Cinacalcet was 10 prior to PBS-listing (2006-7) and peaked at 67 during PBS-listing (2010). There were 21 patients on Cinacalcet after delisting. Among those, 14 (67%) patients subsequently ceased, 3 (14%) proceeded to parathyroidectomy and 4 (19%) remain on Cinacalcet to date. Of those that ceased, the mean serum calcium, phosphate and PTH levels were 2.46±0.19, 1.40±0.47, 383±287 respectively and post-cessation were 2.53±0.21 (p=0.14), 1.34±0.66 (p=0.31), 464±403 (p=0.33) respectively.  The parathyroidectomy rate was 1.73% (2006-7) before PBS-listing, 1.55% (2008-14) while PBS-listed and 2.43% (2015-6) post-PBS-delisting.

Conclusions: No significant change in biochemical profile and PTH was observed with cessation of Cinacalcet and return to standard therapy. However, there was an increased number of hPTH parathyroidectomy following PBS-delisting that we hypothesise will be transient.

IS THE EFFICACY OF NUTRITIONAL VITAMIN D (CHOLECALCIFEROL) COMPARABLE TO ACTIVE VITAMIN D (CALCITRIOL) AS MAINTENANCE THERAPY IN DIALYSIS DEPENDENT CHRONIC KIDNEY DISEASE PATIENTS?

CW NG1, SD YAP2, R RAJ3, M MATHEW3

1Peninsula Health, Frankston, Victoria; 2Alfred Health, Melbourne, Victoria; 3Launceston General Hospital, Launceston, Tasmania

Aim: This study investigated cholecalciferol’s efficacy in maintaining serum calcium in adult dialysis dependent chronic kidney disease patients.

Background: Dialysis dependent chronic kidney disease patients have reduced renal 1-α-hydroxylase and consequently insufficient active vitamin D activity, which is often manifested as hypocalcaemia. Calcitriol is traditionally used as not needing further renal conversion. However, it can cause increased phosphate absorption from gut. There is evidence of persistent extra-renal 1-α-hydroxylase activity in these patients. Hence, cholecalciferol has been proposed as potential alternative therapy.

Methods: This twelve-week pilot prospective interventional cohort study was conducted across three dialysis units in Tasmania. Adult dialysis patients on pre-existing calcitriol and normal serum calcium were enrolled. Their calcitriol was then changed to cholecalciferol. Bloods including calcium, phosphate, parathyroid hormone, alkaline phosphatase, 25-hydroxyvitamin D3 and 1,25-dihydroxyvitamin D3 were sampled at baseline, 4-week, 8-week and 12-week post therapy change. Therapy success was defined as ability of cholecalciferol to maintain serum calcium, and the successful proportion was calculated.

Results: From February till April 2016, 112 patients were screened and total 13 patients were enrolled. 12 of 13 participants succeeded cholecalciferol therapy at end of study. When compared to baseline, there was no significant difference to serum calcium, phosphate and parathyroid hormone at end of study. There was statistically significant rise in serum alkaline phosphatase (mean increase 19.1 U/L, P=0.004) and 25-hydroxyvitamin D3 (mean increase 24.7 nmol/L, P<0.001) at week 12. Serum 1,25-dihydroxyvitamin D3 showed significant initial drop at week 4 (mean reduction 28.1 pmol/L, P<0.001) and week 8 (mean reduction 20.2 pmol/L, P<0.001), but exhibited no significant difference by week 12.

Conclusions: Cholecalciferol can maintain serum calcium in adult chronic kidney disease patients on dialysis.

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