A Phase 4 interventional study of Paricalcitol and Calcitriol in Cardiorenal Syndrome and Chronic Allograft Nephropathy, sponsored by Ural State Medical University. Completed at 2 sites in 2 countries. Open to male participants aged 40 Years to 75 Years. Per ClinicalTrials.gov, last updated 2015-06-09.
Sponsored by Ural State Medical University · Phase 4, Interventional, and Treatment
We hypothesize that paricalcitol and calcitriol in dose-dependent manner are effective for the management of chronic allograft dysfunction (CAD), protection and repair of kidney and heart, management of chronic renocardiac syndrome (CRS). We assume that paricalcitol can have some advantages if compare with calcitriol or cholecalciferol due to absence of calcemic and phosphatemic complications alongside with great beneficial potential.
Paricalcitol and calcitriol are identically effective for the management of chronic allograft dysfunction (CAD), protection and repair of kidney and heart, management of chronic renocardiac syndrome (CRS). Vitamin D can reduce progression of CAD. Activation of VDR in proximal part of nephron leads to rapid non-genomic beneficial effects with urgent multilevel protection of the most functionally important portion of kidney. Rising expression of VDR in distal portions of nephron stimulates slows genomic effects with some local repair responses.
Hormone D may stimulate recruitment and activity of the different origin stem-progenitor cells (SPCs) with beneficial effects on different stages of regeneration by force of para- and autocrine activity. SPCs are revealing mostly in interstitium and among fibroblast-like cells. Vitamin D did not confirm efficacy as a tool for management of mesenchymal stem cells (MSCs) in human however it needs more research experimental evidences due to multifactorial influence on SPCs in human being including immunosuppressive and bone-marrow-related effects of cyclosporine in kidney transplant (Tx) patients. Paricalcitol and calcitriol can slow down migration and infiltration of MSC into interstitium and vessel wall. The side population of mature and SPCs (first of all, with bone-marrow and mesenchymal phenotype) is the most metabolically and functionally active portion of cells with high sensitivity to vitamin D receptor (VDR) activation that responsible for repair of tissue.
The most optimal scheme of treatment with vitamin D in patients with CAD and CRS is an administration of paricalcitol with dose 2-4 μg daily and supplemental intake of vitamin D including special diet, multivitamins, and others with optimal dose until 1800 international units (IU) but excluding insolation as a factor of skin carcinoma. High-dose medicinal intake of calcitriol (until 6 mcg and higher) showed relatively high efficacy but rather excessive level of complications mediated with mineral metabolism.
Paricalcitol and calcitriol may significantly improve contractility of myocardium and reduce cardiovascular risk, heart failure (HF) and hypertension with some beneficial effects on cardiorenal axis and renin-angiotensin-aldosterone system.
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Exclusion Criteria:
6-8 μg daily per os (orally) without special diet
Drug: Paricalcitol
2-4 μg daily orally under with dietary restrictions of vitamin D
Drug: Calcitriol
alendronate sodium/ cholecalciferol capsules with recommended daily allowance equals 1200-2400 IU per day
Drug: Cholecalciferol
intake of cholecalciferol in food and multivitamins, less than 400-900 IU per day
Dietary Supplement: Supplemental
paricalcitol group (6-8 μg daily per os - orally - without special diet)
Also known as: Zemplar
calcitriol group (2-4 μg daily orally under with dietary restrictions of vitamin D)
Also known as: Rocaltrol
cholecalciferol group (intake of cholecalciferol with recommended daily allowance equals 1200-2400 IU per day)
Also known as: Fosamax
intake of cholecalciferol in food and multivitamins, less than 400-900 IU per day
Also known as: Diet, sun, multivitamin drugs, food
CAD (Chronic Allograft Dysfunction) Degree
Beyond 180 days, chronic allograft dysfunction (CAD) was characterized by mean Banff degree (revised 2005/2007 criteria) with the data of renal biopsy material. Renal tissue was recovered during routined biopsy. We assessed antibody-mediated rejection, borderline changes, T-cell-mediated rejection, interstitial fibrosis and tubular atropthy, and other changes. Grades: Grade I. Mild interstitial fibrosis and tubular atrophy (\<25% of cortical area) II. Moderate (26-50%) III. Severe (\>50%) (may include non-specific vascular and glomerular sclerosis)
Time frame: day 180 after Tx (transplantation)
Heart Failure (HF)
NYHA (New York Heart Association) functional class verified with veloergometry probe and by NYHA clinical classification NYHA Class Symptoms I No symptoms and no limitation in ordinary physical activity, e.g. shortness of breath when walking, climbing stairs etc. II Mild symptoms and slight limitation during ordinary activity. III Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances (20-100 m). Comfortable only at rest. IV Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients.
Time frame: on day 180 after Tx (transplantation)
GFR (Glomerular Filtration Rate)
Estimated glomerular filtration rate (eGFR) was calculated using the abbreviated form of the Modification of Diet in Renal Disease (MDRD) study equation: eGFR = exp (5.228 - 1.154 × ln (serum creatinine) - 0.203 × ln (age). Concerning of GFR with Tc99m DTPA renography was used for the complex analysis of renal function. Camera based GFR estimated from Tc99m DTPA renography was named Gates GFR.
Time frame: on day 180
CAD (Chronic Allograft Dysfunction) Degree
CAD degree measured by Banff score after routine renal biopsy (revised 2005/2007 criteria). We assessed antibody-mediated rejection, borderline changes, T-cell-mediated rejection, interstitial fibrosis and tubular atropthy, and other changes. Grades: Grade I. Mild interstitial fibrosis and tubular atrophy (\<25% of cortical area) II. Moderate (26-50%) III. Severe (\>50%) (may include non-specific vascular and glomerular sclerosis)
Time frame: on day 90
Serum Creatinine
After an overnight fast, plasma concentrations of hemoglobin, creatinine, cholesterol, glucose, total calcium, and phosphate were measured using an autoanalyzer as described by Adorini L. (2005)
Time frame: on day 180 after Tx
Number of Circulating SP (Side Population) Stem-Progenitor Cells
Renal cells and solid tissue were obtained from the normal portion of cortex obtained from surgically removed kidneys or by standart biopsy on day 180. Cytofluorimetric analysis and immunofluorescence were performed as described by Oliver J.A. (2004). Sorting and analysis of different cells was done on a FACS (fluorescent activated cell sorting) and by flow cytometry. Cells were analyzed with EPICS systems (Beckman Coulter). Quantification of mRNA expression was achieved using Assays-on-Demand gene expression kits and the ABI PRISM 7000 Sequence Detection System (Applied Biosystem).
Time frame: on day 180
VDR (Vitamin D Receptor) Expression in Myocardium
VDR content was determined by using an ELISA developed in this laboratory. The protein concentration of the homogenates was determined by the method of Bradford (1976), using BSA as a standard.
Time frame: on day 180
VDR (Vitamin D Receptor) Expression in Kidney
VDR content was determined by using an ELISA developed in this laboratory. The protein concentration of the homogenates was determined by the method of Bradford (1976), using BSA as a standard.
Time frame: on day 180
Systolic Blood Pressure
SBP measured by routine method
Time frame: on day 180
Coronary Calcium Score
Bone mineral density assessed by dual-energy X-ray absorptiometry (DXA) of the whole body, lumbar spine and hip was performed using Hologic scanners (QDR 1000W or QDR 2000). The total Agatston coronary calcium score (CCS) was measured as the sum of calcified plaque scores of all the coronary arteries. The amount of calcium present in the coronary arteries is scored according to the Agatson scale, as follows: 0 - no identifiable disease; 1 to 99 - mild disease; 100 to 399 - moderate disease; 400 or higher - severe disease.
Time frame: on day 180
A total of 120 patients (Russian and dutch caucasian, kidney recipients with vitamin D deficiency defined as 25(OH)D \< 30 ng/mL) were assigned on the basis of Ural Institute of Cardiology. Nine of the 120 patients were subsequently excluded due to protocol violation. All the patients had given their written informed consents.
| Milestone | Paricalcitol Treatment | Calcitriol Treatment | Cholecalciferol | Supplemental |
|---|---|---|---|---|
| Started | 30 | 30 | 30 | 30 |
| Completed | 28 | 28 | 26 | 27 |
| Not completed | 2 | 2 | 4 | 3 |
| Withdrew: Protocol violation | 2 | 2 | 4 | 3 |
Beyond 180 days, chronic allograft dysfunction (CAD) was characterized by mean Banff degree (revised 2005/2007 criteria) with the data of renal biopsy material. Renal tissue was recovered during routined biopsy. We assessed antibody-mediated rejection, borderline changes, T-cell-mediated rejection, interstitial fibrosis and tubular atropthy, and other changes. Grades: Grade I. Mild interstitial fibrosis and tubular atrophy (\<25% of cortical area) II. Moderate (26-50%) III. Severe (\>50%) (may include non-specific vascular and glomerular sclerosis)
| Scores on a Banff scale | Paricalcitol Treatment | Calcitriol Treatment | Cholecalciferol | Supplemental |
|---|---|---|---|---|
| CAD (Chronic Allograft Dysfunction) Degree | 1.24 ± 0.14 | 1.22 ± 0.42 | 1.43 ± 0.22 | 1.68 ± 0.36 |
NYHA (New York Heart Association) functional class verified with veloergometry probe and by NYHA clinical classification NYHA Class Symptoms I No symptoms and no limitation in ordinary physical activity, e.g. shortness of breath when walking, climbing stairs etc. II Mild symptoms and slight limitation during ordinary activity. III Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances (20-100 m). Comfortable only at rest. IV Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients.
| NYHA functional class of HF | Paricalcitol Treatment | Calcitriol Treatment | Cholecalciferol | Supplemental |
|---|---|---|---|---|
| Heart Failure (HF) | 1.8 ± 0.2 | 1.9 ± 0.3 | 1.9 ± 0.1 | 2.5 ± 0.2 |
Estimated glomerular filtration rate (eGFR) was calculated using the abbreviated form of the Modification of Diet in Renal Disease (MDRD) study equation: eGFR = exp (5.228 - 1.154 × ln (serum creatinine) - 0.203 × ln (age). Concerning of GFR with Tc99m DTPA renography was used for the complex analysis of renal function. Camera based GFR estimated from Tc99m DTPA renography was named Gates GFR.
| ml/min/1.73 m^2 | Paricalcitol Treatment | Calcitriol Treatment | Cholecalciferol | Supplemental |
|---|---|---|---|---|
| GFR (Glomerular Filtration Rate) | 84 ± 11 | 81 ± 9 | 76 ± 10 | 54 ± 9 |
CAD degree measured by Banff score after routine renal biopsy (revised 2005/2007 criteria). We assessed antibody-mediated rejection, borderline changes, T-cell-mediated rejection, interstitial fibrosis and tubular atropthy, and other changes. Grades: Grade I. Mild interstitial fibrosis and tubular atrophy (\<25% of cortical area) II. Moderate (26-50%) III. Severe (\>50%) (may include non-specific vascular and glomerular sclerosis)
| Scores on a Banff scale | Paricalcitol Treatment | Calcitriol Treatment | Cholecalciferol | Supplemental |
|---|---|---|---|---|
| CAD (Chronic Allograft Dysfunction) Degree | 1.24 ± 0.14 | 1.22 ± 0.42 | 1.43 ± 0.22 | 1.68 ± 0.36 |
After an overnight fast, plasma concentrations of hemoglobin, creatinine, cholesterol, glucose, total calcium, and phosphate were measured using an autoanalyzer as described by Adorini L. (2005)
| mg/dL | Paricalcitol Treatment | Calcitriol Treatment | Cholecalciferol | Supplemental |
|---|---|---|---|---|
| Serum Creatinine | 2.5 ± 0.9 | 2.5 ± 0.7 | 2.8 ± 0.7 | 4.1 ± 1.1 |
Renal cells and solid tissue were obtained from the normal portion of cortex obtained from surgically removed kidneys or by standart biopsy on day 180. Cytofluorimetric analysis and immunofluorescence were performed as described by Oliver J.A. (2004). Sorting and analysis of different cells was done on a FACS (fluorescent activated cell sorting) and by flow cytometry. Cells were analyzed with EPICS systems (Beckman Coulter). Quantification of mRNA expression was achieved using Assays-on-Demand gene expression kits and the ABI PRISM 7000 Sequence Detection System (Applied Biosystem).
| per cent of SP cells | Paricalcitol Treatment | Calcitriol Treatment | Cholecalciferol | Supplemental |
|---|---|---|---|---|
| Number of Circulating SP (Side Population) Stem-Progenitor Cells | 7.6 ± 0.9 | 6.5 ± 1 | 5.7 ± 0.8 | 4.2 ± 0.7 |
VDR content was determined by using an ELISA developed in this laboratory. The protein concentration of the homogenates was determined by the method of Bradford (1976), using BSA as a standard.
| fmol VDR/ mg protein | Paricalcitol Treatment | Calcitriol Treatment | Cholecalciferol | Supplemental |
|---|---|---|---|---|
| VDR (Vitamin D Receptor) Expression in Myocardium | 801 ± 112 | 715 ± 96 | 654 ± 88 | 389 ± 77 |
VDR content was determined by using an ELISA developed in this laboratory. The protein concentration of the homogenates was determined by the method of Bradford (1976), using BSA as a standard.
| fmol VDR/ mg protein | Paricalcitol Treatment | Calcitriol Treatment | Cholecalciferol | Supplemental |
|---|---|---|---|---|
| VDR (Vitamin D Receptor) Expression in Kidney | 584 ± 103 | 599 ± 102 | 478 ± 79 | 333 ± 62 |
SBP measured by routine method
| mmHg | Paricalcitol Treatment | Calcitriol Treatment | Cholecalciferol | Supplemental |
|---|---|---|---|---|
| Systolic Blood Pressure | 143 ± 22 | 141 ± 9 | 147 ± 13 | 165 ± 19 |
Bone mineral density assessed by dual-energy X-ray absorptiometry (DXA) of the whole body, lumbar spine and hip was performed using Hologic scanners (QDR 1000W or QDR 2000). The total Agatston coronary calcium score (CCS) was measured as the sum of calcified plaque scores of all the coronary arteries. The amount of calcium present in the coronary arteries is scored according to the Agatson scale, as follows: 0 - no identifiable disease; 1 to 99 - mild disease; 100 to 399 - moderate disease; 400 or higher - severe disease.
| units on a scale | Paricalcitol Treatment | Calcitriol Treatment | Cholecalciferol | Supplemental |
|---|---|---|---|---|
| Coronary Calcium Score | 530 ± 423 | 611 ± 502 | 524 ± 122 | 990 ± 120 |
Collected over 6 months. Non-serious events are listed at a 0% frequency threshold.
| Group | Deaths | Serious | Other |
|---|---|---|---|
| Paricalcitol Treatment | — | 9/30 (30%) | 10/30 (33.3%) |
| Calcitriol Treatment | — | 21/30 (70%) | 15/30 (50%) |
| Cholecalciferol | — | 6/30 (20%) | 9/30 (30%) |
| Supplemental | — | 8/30 (26.7%) | 9/30 (30%) |
| Event | Paricalcitol Treatment | Calcitriol Treatment | Cholecalciferol | Supplemental |
|---|---|---|---|---|
| HypophospatemiaEndocrine disorders | 7/30 | 16/30 | 5/30 | 1/30 |
| Myocardial infarctionCardiac disorders | 0/30 | 1/30 | 0/30 | 5/30 |
| HypercalcemiaEndocrine disorders | 2/30 | 4/30 | 0/30 | 0/30 |
| StrokeNervous system disorders | 0/30 | 0/30 | 1/30 | 2/30 |
| Event | Paricalcitol Treatment | Calcitriol Treatment | Cholecalciferol | Supplemental |
|---|---|---|---|---|
| FatigueGeneral disorders | 5/30 | 7/30 | 3/30 | 4/30 |
| DiarrheaGastrointestinal disorders | 4/30 | 5/30 | 4/30 | 7/30 |
| Increased hypertensionCardiac disorders | 4/30 | 3/30 | 5/30 | 6/30 |
| PainGeneral disorders | 4/30 | 4/30 | 5/30 | 4/30 |
| EdemaMetabolism and nutrition disorders | 4/30 | 4/30 | 5/30 | 3/30 |
| Chest PainGeneral disorders | 1/30 | 2/30 | 4/30 | 3/30 |
| AnorexiaPsychiatric disorders | 0/30 | 4/30 | 0/30 | 0/30 |
| Taste perversionsGastrointestinal disorders | 3/30 | 4/30 | 2/30 | 2/30 |
| DizzinessNervous system disorders | 3/30 | 3/30 | 2/30 | 4/30 |
| VertigoNervous system disorders | 3/30 | 2/30 | 4/30 | 3/30 |
| Age, Categorical(Participants) | Paricalcitol Treatment | Calcitriol Treatment | Cholecalciferol | Supplemental | Total |
|---|---|---|---|---|---|
| <=18 years | 0 | 0 | 0 | 0 | 0 |
| Between 18 and 65 years | 28 | 28 | 26 | 27 | 109 |
| >=65 years | 2 | 2 | 4 | 3 | 11 |
| Age, Continuous(years) | Paricalcitol Treatment | Calcitriol Treatment | Cholecalciferol | Supplemental | Total |
|---|---|---|---|---|---|
| Mean | 56 ± 4 | 59 ± 4 | 58 ± 5 | 57 ± 4 | 58 ± 9 |
| Sex: Female, Male(Participants) | Paricalcitol Treatment | Calcitriol Treatment | Cholecalciferol | Supplemental | Total |
|---|---|---|---|---|---|
| Female | 0 | 0 | 0 | 0 | 0 |
| Male | 30 | 30 | 30 | 30 | 120 |
| Region of Enrollment(participants) | Paricalcitol Treatment | Calcitriol Treatment | Cholecalciferol | Supplemental | Total |
|---|---|---|---|---|---|
| Russian Federation | 30 | 30 | 30 | 30 | 120 |
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Ural State Medical University