Alfacalcidol in CKD-MBD - A Fresh Look

Chronic Kidney Disease Mineral and Bone Disorder (CKD-MBD) is a result of metabolic changes that occur in patients with chronic kidney disease. The consequences are renal osteodystrophy and vascular calcifications, especially seen in the more advanced stages of chronic renal failure. Different treatment regimens including dietary phosphate restriction, oral phosphate binders and active vitamin D supplementation have been used during the last 30 years. Alfacalcidol (1a(OH)D3) is an analog of vitamin D3, a pro-drug of 1,25(OH)2D3, which is hydroxylated at position number 1 and therefore bypasses the impaired 1a-hydroxylation in the diseased kidneys of patients with chronic renal failure. Alfacalcidol was the first vitamin D analog produced in the 1970’s, available for treatment of renal osteodystrophy in all stages of CKD. It has been used in most European countries since then, either alone or in combination with calcimimetics or bisphosphonates and shown to attenuate all aspects of CKD-MBD. During the last 20 years, new vitamin D analogs with a potentially less effect on plasma calcium and phosphate and a more positive effect on the cardiovascular system have been on the market. None have demonstrated superiority compared to alfacalcidol. Based on the available clinical data, alfacalcidol can still be prescribed for treatment of secondary hyperparathyroidism in both early and late stages of CKD, besides being affordable to many patients, which is an important factor in many countries. Hopefully, new drugs will be available in the future, which have positive effects on mortality and cardiovascular morbidity in CKD.