Mineral metabolism treatment strategies for kidney failure trend toward ‘equipoise’
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From 2008 to 2015, prescriptions for vitamin D sterols trended downward while prescriptions for phosphate binders and cinacalcet increased for patients with kidney failure at 359 facilities affiliated with Dialysis Clinic Inc.
“Mineral metabolism is commonly disordered in patients with kidney failure on hemodialysis and associates with adverse outcomes,” Rasheeda Hall, MD, and colleagues wrote in a study published in the Clinical Journal of the American Society of Nephrology. “The best pharmacologic management strategies are unknown, with few mineral metabolism practices supported by randomized controlled clinical trials of clinical, as opposed to biochemical, outcomes.”
To identify trends in mineral management pharmacotherapies, Hall and colleagues analyzed data from 23,549 patients treated with hemodialysis (median age, 64; Black, 35%; women, 43%). They grouped patients into three cohorts based on year of hemodialysis initiation (2006 to 2008, 2009 to 2011 and 2012 to 2015).
The proportion of patients prescribed vitamin D sterol-based strategies decreased at dialysis initiation (first cohort, 15% vs. third cohort, 5%) and after 18 months of dialysis (first cohort, 52% vs. third cohort, 34%). Patients in the third cohort were more likely to be prescribed a cinacalcet treatment (first cohort, OR = 1.7; 95% CI, 1.5-2.1; second cohort, OR = 2; 95% CI, 1.8-2.5 vs. third cohort, OR = 2.6; 95% CI, 2.2-3.2) or phosphate binder (first cohort, OR = 1.6; 95% CI, 1.5-1.8; second cohort, OR = 1.9; 95% CI, 1.7-2.1 vs. third cohort, OR = 3.5; 95% CI, 3-4.2). The likelihood of no mineral metabolism medication treatment also increased over time (first cohort, OR = 1.7; 95% CI, 1.5-2; second cohort, OR = 1.8; 95% CI, 1.6-2.2 vs. third cohort, OR = 3.2; 95% CI, 2.7-4).
“In summary, our data demonstrate secular changes in mineral metabolism treatment over the past decade, accompanied by growing practice variation,” researchers wrote. “The growing equipoise is an opportunity for natural experiments and randomized controlled trials to build the evidence base that is needed in nephrology for stronger, evidence-based recommendations in this important area in hemodialysis care.”
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