Significance of endotoxaemia in chronic kidney disease.

the mean of all PTH, calcium and phosphorus measurements obtained during the whole period of 9 months, before (PTH 590.4 pg/ml) and 9 months after the treatment with cinacalcet (PTH 414.2 pg/ml). In the Table, the PTH, calcium and phosphorus at time 0 (just before starting cinacalcet) and after 9 months of treatment with cinacalcet are shown. Control of secondary hyperparathyroidism (SHPT) in CKD patients is frequently difficult [1,2] and it has important implications for patient morbidity and mortality [3,4]. Fortunately, in recent years, there have been important advances with the appearence of new drugs which represent a clear benefit in the treatment of this problem. The ability of cinacalcet to reduce PTH secretion, along with reductions in the serum calcium, phosphorus and calcium–phosphorus product, provides an alternative to the traditional treatment paradigm, and should be an addition to our therapeutic strategy in the management of SHPT. In addition to its effects on PTH and mineral metabolism, cinacalcet has demonstrated favourable effects on important clinical outcomes: combined results from four clinical trials (cinacalcet randomization) led to significant reductions in the risk of parathyroidectomy, fractures and cardiovascular hospitalization, along with improvements in self-reported physical function and diminished pain [5]. On the other hand, the pleiotropic effects of vitamin D have recently been highlighted; vitamin D regulates cell proliferation and differentiation, modulates the immune system, and is involved in several endocrine systems. Vitamin D metabolites therapy provides survival benefits and, certainly, paricalcitol has demonstrated good results in terms of PTH, calcium and phosphorus control, as well as a reduced mortality risk when comparing treated and untreated patients [6]. The optimal treatment for SHPT in HD patients is yet to be established. It is possible that the combined use of both drugs (cinacalcet and paricalcitol) might offer some therapeutical advantages: we should further investigate the use of these drugs (either alone or in combination) in different patient populations and see the outcomes in terms of mortality, morbidity and costs, in order to establish the most efficient treatment in each situation.