Cinacalcet in treatment of the secondary hyperparathyroidism relapse in patients on dialysis

Abstract

The incidence of the secondary hyperparathyroidism (HPT) after parathyroidectomy (PTE) in dialysis patients accounts for 10-80%. We present a case of the successful cinacalcet treatment of a female hemodialysis (HD) patient with HPT relapse. A female patient (aged 40 years) with the diabetes mellitus I (since 11 years of age) has been undergoing substitution therapy on continuous ambulatory peritoneal dialysis (CAPD) since October 2004. Insulin and erythropoietin treatment has been continued as well as taking phosphate binders with calcium and calcitriol analogs (with intervals due to hyperphosphatemia). Нb=117 g/L, Са=2.2, Р=1.8 mmoles/L, PTH=272 pg/ml, total alkaline phosphatase (AlP)=69 U/L (normal level 31-115), and Нb1С=9.2%. Since December 2007, the patient has been treated with HD (due to inadequacy of the CAPD ultrafiltration); in 2009, her left leg was amputated (gangrene). Taking into account unconntrolled HPT developed in the patient (PTH=2058 pg/ml, Са=2.4, Р=2.7 mmoles/L, and AlP=290 U/L), PTE was carried out in October 2007: enlarged (∅ 12 mm) right inferior parathyroid gland was removed, other glands weren’t revealed. Patient’s condition in postoperative period was satisfactory (PTH 70–120 pg/ml, Са=1.5-1.9, Р=1.3–1.5 mmoles/L, and AlP=145-68 U/L). Since 2009, the signs of the secondary HPT recurrence: PTH 1436 pg/ml., Са=2.4, Р=2.3 mmoles/L, and AlP=184 U/L. Increasing the dose of calcitriol analogs caused hypercalcemia and hyperphosphatemia. Ultrasound investigation and scintigraphy with 99mТс-technetril also have not revealed parathyroid glands. The negative dynamics was detected by the DEXA scanning shown by the T-scores at the hip, spine and left forearm. Cinacalcet treatment was started: the initial dose 30 mg/day, in a month − 60 mg/day, and in 6 months and till now − 45 mg/day. The sought-for values of the mineral-osseous metabolism have been achieved. Bone mineral density stabilized in the left forearm (1/3 radius T-score -3.7 vs. -3.8) and increased in the hip and spine (neck T-score Cinacalcet is an efficient preparation and may be one of choice for some patients to treat HPT relapses.