Comparison of Semi-Automated and Manual Measurements of Carotid Intima-Media Thickening

Carotid intima-media thickening (CIMT) is a marker of both arteriosclerotic and atherosclerotic risks. Technological advances have semiautomated CIMT image acquisition and quantification. Studies comparing manual and automated methods have yielded conflicting results possibly due to plaque inclusion in measurements. Low atherosclerotic risk subjects (n = 126) were recruited to minimise the effect of focal atherosclerotic lesions on CIMT variability. CIMT was assessed by high-resolution B-mode ultrasound (Philips HDX7E, Phillips, UK) images of the common carotid artery using both manual and semiautomated methods (QLAB, Phillips, UK). Intraclass correlation coefficient (ICC) and the mean differences of paired measurements (Bland-Altman method) were used to compare both methodologies. The ICC of manual (0.547 ± 0.095 mm) and automated (0.524 ± 0.068 mm) methods was R = 0.74 and an absolute mean bias ± SD of 0.023 ± 0.052 mm was observed. Interobserver and intraobserver ICC were greater for automated (R = 0.94 and 0.99) compared to manual (R = 0.72 and 0.88) methods. Although not considered to be clinically significant, manual measurements yielded higher values compared to automated measurements. Automated measurements were more reproducible and showed lower interobserver variation compared to manual measurements. These results offer important considerations for large epidemiological studies

Case Series: Calciphylaxis: Do Calcimimetics Have a Role in Management?

Introduction: Calciphylaxis is a rare but serious systemic disorder characterized by small vessel calcification leading to tissue ischemia. Abnormalities in mineral metabolism that are often associated with uremia are important predisposing factors. The optimal therapy for calciphylaxis is prevention through rigorous control of phosphate and calcium balance. We here present two cases of calciphylaxis that responded to an intensive treatment protocol based on cinacalcet. Case 1: The first patient was a 60-year old lady who was on regular hemodialysis for two years. She presented with four months history of painful, necrotic, non-healing ulcers on her right leg despite intact peripheral pluses. Her calcium level was 11.6 mg/dl, phosphate 6.6 mg/dl and parathyroid hormone (PTH) 1450 pg/ml. The diagnosis of calciphylaxis was confirmed by ulcer punch biopsy. The patient was treated with cinacalcet 90 mg daily, increasing the dose of non-calcium based phosphate binders, low-calcium dialysate, and withdrawal of alfacalcidol. At the end of six months of this therapy, the ulcers almost healed and renal bone profile normalized. Case 2: The second patient was a 58-year old gentleman with advanced chronic allograft nephropathy. He presented with painful, non healing ulcers on his calf. His calcium level was 12.4 mg/dl, phosphate 5.9 mg/dl and PTH 1009 pg/ml and he had recently stopped using alphacalcidol. He was treated with cinacalcet 90 mg daily and increasing the dose of non-calcium based phosphate binders. Within three months, his renal bone profile was within target levels and his ulcers had significantly improved. Conclusion: Calcimimetics have a potential role in the treatment of calciphylaxis, as demonstrated by these two cases. Keywords: Calcimimetics; Calciphylaxis; Cinacalce

Cinacalcet reduces plasma intact parathyroid hormone,serum phosphate and calcium levels in patients with secondary hyperparathyroidismirrespective of its severity

Aims: To evaluate the relationship between the severity of secondary hyperparathyroidism (SHPT) - defined in terms of baseline plasma intact parathyroid hormone (iPTH) level -and the magnitude of response to cinacalcet. Materials and methods: In this post hoc analysis, data were pooled from three randomized, placebo-controlled trials in which dialysis patients with iPTH >= 300 pg/ml were dose-titrated with cinacalcet or placebo in addition to conventional treatment to achieve iPTH = 1,000 pg/ml), and the impact of baseline iPTH on changes in iPTH, phosphate (P), calcium (Ca) and calcium-phosphate product (Ca x P) was evaluated. Results: Cinacalcet reduced iPTH (47% reduction), P (9%), Ca (7%), and Ca x P (15%) across all subgroups. For patients receiving cinacalcet, the mean percentage reduction from baseline in iPTH varied from 35 to 55%, being consistently decreased across the severity subgroups. The mean absolute change in iPTH was more pronounced in patients with higher baseline iPTH levels, particularly in the >= 1,000 pg/ml subgroup vs. the other subgroups. However, as baseline iPTH levels increased, iPTH = 800 pg/ml) treated with cinacalcet compared with patients with less severe disease (iPTH 300 - < 800 pg/ml). Conclusions: Cinacalcet lowers plasma iPTH and serum P, Ca and Ca x P levels in dialysis patients with SHPT, regardless of disease severity. Patients with more severe disease experienced greater reductions in PTH and P, but fewer achieved iPTH <= 250 pg/ml by the efficacy assessment phase. Use of cinacalcet when baseline PTH is lower may result in more stable control of SHPT and help to control bone and mineral alterations