Chronic Kidney Disease, Hyperparathyroidism
Conditions
Keywords
secondary hyperparathyroidism, phosphate, calcium, chronic kidney disease
Brief summary
The hypothesis underlying this study is that phosphate interferes with PTH-mediated calcium reabsorption in the distal nephron and thereby necessitates supranormal \[PTH\]to maintain normocalcemia in chronic kidney disease. This study will examine the hypothesis with measures of phosphate homeostasis and calcium reabsorption. A double-blind trial of the intestinal phosphate binder sevelamer carbonate will be employed to examine whether reductions in phosphate influx alter distal nephron phosphate concentration and the \[PTH\] required for calcium reabsorption in the expected manner.
Detailed description
The parathyroid hormone concentration (\[PTH)\] rises as glomerular filtration rate (GFR) falls. This almost universal phenomenon is called secondary hyperparathyroidism (SHPT). \[PTH\] rises with dietary phosphate in chronic kidney disease. \[PTH\] also rises with stable dietary phosphate as GFR falls. The mechanism underlying these phenomena is unknown. We hypothesize that phosphate exerts its effect on \[PTH\] in the cortical distal nephron (CDN). Ordinarily, intestinal phosphate absorption does not fall in proportion to GFR as chronic kidney disease (CKD) progresses. Consequently, the concentration of phosphate increases in the cortical distal nephron (CDN), where PTH regulates tubular calcium reabsorption. We speculate that increased \[P\]cdn reduces the concentration of free calcium through complexation, and thereby necessitates high \[PTH\] for achievement of calcium reabsorption sufficient to maintain normocalcemia. We can show algebraically that \[P\]cdn is proportional to the ratio EP/Ccr, where EP is the urinary excretion rate of phosphate and Ccr is creatinine clearance, a surrogate for GFR. EP/Ccr can be calculated from measurements in aliquots of serum and urine as \[P\]u\[cr\]s/\[cr\]u. If our hypothesis is correct, we anticipate that \[PTH\] will be proportional to EP/Ccr in CKD, and that delta \[PTH\] will be proportional to delta EP/Ccr obtained with sequential determinations. We will study 30 patients with CKD and a comparable number of controls. All subjects will have normocalcemia. Controls will be seen once for informed consent, and once in the fasting state between 8:00 a.m. and 10:00 a.m. for collection of urine and blood specimens. Patients with CKD will be seen at five visits at intervals of four weeks. At the first visit, we will obtain informed consent and obtain a specimen for measurement of 25-hydroxyvitamin D (25OHD). At visits 2-5, we will obtain necessary specimens to measure concentrations of PTH, fibroblast growth factor 23 (FGF23), 25OHD, and 1,25-dihyroxyvitamin D (1,25(OH)2D). We will also measure ionized and ultrafilterable calcium, creatinine, and phosphorus in serum and calcium, phosphorus, and creatinine in urine. These measurements will enable us to follow the effects of interventions on hormone concentrations and parameters of calcium and phosphorus homeostasis. At visit 2 we will prescribe vitamin D in accordance with \[25OHD\] obtained at visit 1. For \[25OHD\] \< 32 ng/mL, doses will be 50,000 units/d of D2 for one week, followed by 2000 mg/d of D2 for 3 weeks. For \[25OHD\] \> 32 ng/mL, the dose will be D3 2000 mg/d for four weeks. The purpose of this intervention is to minimize the likelihood that vitamin D insufficiency or deficiency contributes to SHPT. At visit 3, we will instruct patients in a phosphate-restricted diet. At visit 4 we will quantify the metabolic effects of the diet, and will randomly assign patients to receive either placebo or sevelamer carbonate 800 mg tablets, 3 with each meal. At visit 5, we will quantify the effects of the two interventions on parameters of calcium and phosphate homeostasis and on hormone concentrations. We will view positive regressions of \[PTH\] on EP/Ccr and of ∆\[PTH\] on ∆EP/Ccr as evidence for our hypothesis.
Interventions
DRUGsevelamer carbonate
2400 mg with each meal for 4 weeks
DRUGplacebo
3 tablets with each meal
Sponsors
Genzyme, a Sanofi Company
Kenneth R. Phelps, M.D.
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
QUADRUPLE (Subject, Caregiver, Investigator, Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
18 Years to 120 Years
Healthy volunteers
Yes
Inclusion criteria
* eGFR \< 60 ml/min * age at least 18 years
Exclusion criteria
* any primary parathyroid disease
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Fractional Change in [PTH] in CKD After a 4-week Course of Sevelamer Carbonate | 4 weeks | This outcome measure documented the effect of intestinal phosphate-binding on \[PTH\]. Fractional change was calculated as (\[PTH\]post - \[PTH\]pre)/\[PTH\]pre, where 'pre' and 'post' referred respectively to baseline \[PTH\] (before treatment) and \[PTH\] after four weeks of treatment. Reductions were cited as negative numbers, and increments were cited as positive numbers. |
Countries
United States
Participant flow
Recruitment details
Patients with eGFR \< 60 were recruited from renal clinics and randomized to receive 3 tablets of sevelamer or placebo with each meal for four weeks.
Pre-assignment details
Randomization was preceded by a 4-week course of vitamin D (dose determined by plasma \[25OHD\]) and then by a 4-week period of dietary phosphate restriction. The phosphate restriction was continued through the therapeutic trial.
Participants by arm
| Arm | Count |
|---|---|
| Sevelamer Carbonate 2400 mg (3 pills) with each meal
sevelamer carbonate : 2400 mg with each meal for 4 weeks | 14 |
| Placebo Control 3 placebo tablets with each meal; tablets are identical to sevelamer carbonate 800 mg tablets.
placebo : 3 tablets with each meal | 15 |
| Total | 29 |
Withdrawals & dropouts
| Period | Reason | FG000 | FG001 |
|---|---|---|---|
| Overall Study | Adverse Event | 1 | 0 |
Baseline characteristics
| Characteristic | Placebo Control | Sevelamer Carbonate | Total |
|---|---|---|---|
| Age, Categorical <=18 years | 0 Participants | 0 Participants | 0 Participants |
| Age, Categorical >=65 years | 9 Participants | 11 Participants | 20 Participants |
| Age, Categorical Between 18 and 65 years | 6 Participants | 3 Participants | 9 Participants |
| Age, Continuous | 70.1 years STANDARD_DEVIATION 10.5 | 73.7 years STANDARD_DEVIATION 8.5 | 71.8 years STANDARD_DEVIATION 9.6 |
| Region of Enrollment United States | 15 participants | 14 participants | 29 participants |
| Sex: Female, Male Female | 0 Participants | 0 Participants | 0 Participants |
| Sex: Female, Male Male | 15 Participants | 14 Participants | 29 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | — / — | — / — |
| other Total, other adverse events | 1 / 15 | 0 / 15 |
| serious Total, serious adverse events | 0 / 15 | 0 / 15 |
Outcome results
Primary
Fractional Change in [PTH] in CKD After a 4-week Course of Sevelamer Carbonate
This outcome measure documented the effect of intestinal phosphate-binding on \[PTH\]. Fractional change was calculated as (\[PTH\]post - \[PTH\]pre)/\[PTH\]pre, where 'pre' and 'post' referred respectively to baseline \[PTH\] (before treatment) and \[PTH\] after four weeks of treatment. Reductions were cited as negative numbers, and increments were cited as positive numbers.
Time frame: 4 weeks
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Sevelamer Carbonate | Fractional Change in [PTH] in CKD After a 4-week Course of Sevelamer Carbonate | -11.7 percentage of baseline [PTH] | Standard Error 5.8 |
| Placebo Control | Fractional Change in [PTH] in CKD After a 4-week Course of Sevelamer Carbonate | 16.4 percentage of baseline [PTH] | Standard Error 10 |