Bover_EU_Renal.qxp 9/7/07 9:30 am Page 22
Phosphorus Control
been recently published that coronary artery calcification increased likely to be present over time, therapeutic efforts are preferentially aimed
significantly in the first six months after RT, remaining stable afterwards, at attenuating or halting the progression of VC. Eventually, should the
at least during 12 months of follow-up.
84
Changes in calcium and primary insult disappear, VC might regress. Only a few eventual personal
phosphate levels were not associated with VC. On the other hand, short observations and reports suggest that VC may disappear; this
daily haemodialysis was associated with improved fluid and phosphorus phenomenon is particularly described after PTX, supporting the concept
management, a reduction in left ventricular hypertrophy and of slow improvement over time after correction of the major mineral
inflammatory factors and a lower prevalence of moderate or severe VC metabolism derangements. Thus, after four patients showed regression
by radiography.
85
The progression and impact of VC in peritoneal dialysis or disappearance of digital calcification, it has been stated that this
patients has been recently published,
86
whereas the impact of more calcification is more labile than is axial calcification.
54
These findings were
biocompatible membranes, solutions or ultrapure water on VC have not similar in continuous ambulatory peritoneal dialysis (CAPD) patients,
been analysed. where digital calcifications – such as calcifications in muscles, tendons
and joints – were considered more labile.
93
Tumoral calcinosis has been
New treatment options may emerge acting on this new bone–vascular reported to revert in ESRD patients by PTX, intensive dialysis with low-
axis, preventing both bone demineralisation and VC. Bone calcium dialysate, treatment with acetazolamide and other
morphogenetic protein-7 (BMP-7) has been shown to improve VC in LDL- manoeuvres.
94–96
Recently, withdrawal of supraphysiological doses of
receptor null mice fed high-fat/high-cholesterol diets, a model of the calcitriol in calcified rats with normal renal function allowed a rapid
metabolic syndrome with hyperphosphataemia and adynamic bone regression of medial VC and, interestingly, an active cellular process in
disorder when superimposing CKD.
87
BMP-7 treatment corrected the which cells from the monocyte-macrophage lineage seemed to play an
adynamic disorder and corrected hyperphosphataemia. As mentioned important role.
95
above, reversal of the adynamic bone disorder and decreased VC in
experimental CKD by sevelamer has been recently published using this Conclusion
model.
34
Osteoprotegerin inhibits VC induced by warfarin and vitamin In summary, VC is a common problem in CKD patients and should alert
D;
88
thus, osteoprotegerin and anti-receptor activator of nuclear factor- clinicians to identify patients with poor long-term outcomes. VC should
κβ-ligand (RANKL) antibodies may be of interest. Teriparatide (human probably be diagnosed routinely by any available means, starting with
[1-34]-PTH) does not seem to have a role in patients with CKD unless plain X-rays.
3,96
The presence of VC may guide some therapeutic
hypoparathyroidism is present; however, it has been shown to inhibit decisions. While it is generally agreed that the detection of VC should
osteogenic VC in a diabetic mouse model.
89
The potential role of lead to a reduction in calcium intake and more cautious use of vitamin
endothelin antagonists – e.g. bosentan – and calcium channel blockers D, a preferential use of sevelamer, selective VDRAs such as paricalcitol
remains to be fully elucidated.
90,91
Interestingly, calcification in coronary or calcimimetics should be seriously considered. Since the clinical
artery disease can be reversed by ethylene diamine tetraacetic acid advantages of slowing VC remains uncertain, new clinical and/or
(EDTA)-tetracycline long-term chemotherapy.
92
pharmaco-economic prospective studies are definitely needed. Better
drugs do exist, and although the financial burden of new drugs might
Regression of Vascular Calcification significantly limit their widespread use, decisions regarding the use of
There is not much information about regression of VC. Since it is healthcare budgets should be aimed at a better life and optimal
associated with chronic diseases in which the precipitating factors are treatment for patients. ■
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