Trajectories of CKD-MBD biochemical parameters over a 2-year period following diagnosis of secondary hyperparathyroidism: a pharmacoepidemiological study

Abstract

Objectives: To define groups of patients according to the changes of biochemical parameters, that is, serum calcium, phosphate and parathyroid hormone (PTH), over a 2-year follow-up period using group-based multi-trajectory modeling (GBMM) among a cohort of dialysis patients with newly diagnosed secondary hyperparathyroidism (SHPT) (ie, PTH≥500 ng/L for the first time) and to compare their patient characteristics and treatments.

Design: Pharmacoepidemiological study.

Setting: In the 12 dialysis units located in the French region of Lorraine.

Participants: A total of 269 dialysis patients with newly diagnosed SHPT were prospectively included from December 2009 to May 2012 and followed-up for 2 years.

Results: We identified four distinct trajectory groups: 'rapid PTH drop' experiencing a rapid and sharp decrease (over weeks) in PTH level associated with decreasing phosphate level within normal range (n=34; 12.7%), 'gradual PTH decrease' experiencing a gradual and continuous decrease (over months) in PTH level and maintaining phosphate at a middle level throughout the study (n=98; 36.4%), 'slow PTH decrease with high phosphate' experiencing a slow decrease in PTH level associated with a relatively high phosphate level (n=105; 39.0%) and 'uncontrolled SHPT' with high levels of PTH and phosphate throughout the study (n=32; 11.9%). Patients in the 'uncontrolled SHPT' group were significantly (p<0.00001) younger than patients in other groups. Kidney Disease Improving Global Outcomes (KDIGO) targets for PTH, phosphate and calcium were reached simultaneously for 14.9% of patients at baseline and 16.7% at the end of the study. Patients were given cinacalcet more frequently at months 3 and 6 in the 'rapid PTH drop' and at month 24 in the 'uncontrolled SHPT' groups.

Conclusions: Over 2 years following a new SHPT diagnosis, a younger age and a higher rate of alkaline phosphatase were associated to a continuous uncontrolled SHPT. Patients with the lowest PTH at the end of the follow-up tended to receive more often cinacalcet.

Trial registration number: ClinicalTrials.gov number, NCT02888639, post results.

Conflict of interest statement

Competing interests: None declared.

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Figures

Figure 1

Trajectories for parathyroid hormone, calcium and phosphate over the two years after diagnosis of a severe secondary hyperparathyroidism. The solid lines indicate the observed trajectories, and the dashed lines indicate the predicted trajectories with 95% CIs. Blue, ‘rapid PTH drop’ group; red: ‘gradual PTH decrease’ group; green, ‘slow PTH decrease with high phosphate’ group; black, ‘uncontrolled SHPT’ group. PTH, parathyroid hormone; SHPT, secondary hyperparathyroidism.

Figure 2

Cinacalcet prescription according to trajectory groups. Blue, ‘rapid PTH drop’ group; red: ‘gradual PTH decrease’ group; green, ‘slow PTH decrease with high phosphate’ group; black, ‘uncontrolled SHPT’ group. PTH, parathyroid hormone; SHPT, secondary hyperparathyroidism.