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Therapeutic Apheresis and Dialysis 2012; 16(3):248253 doi: 10.1111/j.1744-9987.2012.01061.x 2012 The Authors Therapeutic Apheresis and Dialysis 2012 International Society for Apheresis

Effect of Alfacalcidol Therapy on the Survival of Chronic Hemodialysis Patients

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Mariko Ogawa,1 Tetsuya Ogawa,2 Tomoko Inoue,1 Kuniaki Otsuka,2 and Kosaku Nitta1
1

Department of Medicine, Kidney Center, Tokyo Womens Medical University and 2Department of Medicine, Tokyo Womens Medical University Medical East Center, Tokyo, Japan

Abstract: The aim of this study was to determine the relationship between alfacalcidol therapy and the outcomes of chronic hemodialysis (HD) patients. We collected demographic and clinical baseline data from 190 prevalent HD patients in a regional Japanese cohort. A 5-year survival analysis was performed according to whether the patients were receiving calcitriol analog therapy. Alfacalcidol therapy at a mean dose of 5.2 1.8 mg/week was performed in 89 (46.8%) of the 190 patients. We recorded 38 deaths during the follow-up period, including 19 deaths from cardiovascular events. A KaplanMeier analysis demonstrated that the alfacalcidol users had a signicantly lower rate of all-cause mortality and cardiovascular mor-

tality than the non-users. According to a multivariate Cox proportional hazards model, in addition to the use of alfacalcidol (HR=0.347 [0.1550.714]; P = 0.0035), serum CRP levels (HR= 1.746 [1.1842.442]; P = 0.0071) and non-HDL-cholesterol levels (HR=1.012 [1.0011.022]; P = 0.0267) were identied as independent predictors of all-cause mortality, and the presence of diabetes mellitus (HR=3.720 [1.18212.398]; P = 0.0246) was identied as an independent predictor of cardiovascular mortality. These ndings suggest that low-dose alfacalcidol therapy provides a survival advantage to chronic HD patients. Key Words: Alfacalcidol, Hemodialysis, Mineral metabolism, Survival rate, Vitamin D.

Vitamin D, whether synthesized in the skin in response to exposure to ultraviolet B rays or ingested in the diet, is hydroxylated to 25-hydroxyvitamin D [25(OH)D] in the liver, and 25(OH)D circulates in up to 1000-fold higher concentrations than the most potent vitamin D metabolite, 1,25-dihydroxyvitamin D [1,25(OH)2D, calcitriol] (1). Vitamin D deciency is frequently observed in the majority of HD patients (2). Since the kidney is the main source of circulating 1,25(OH)2D, which is crucial for calcium and phosphorus metabolism as well as PTH homeostasis, supplementation with 1,25(OH)2D and its analogs is routinely provided to many HD patients, and it is associated with improved survival (3). Low serum 25-OHD levels in patients with CKD have been associated with higher mortality (4) and a more frequent

evolution toward ESRD (5). In incident HD patients not treated with calcitriol analogs, vitamin D deciency has been associated with a higher mortality rate (6,7). An observational study of HD patients has reported that calcitriol analog therapy with alfacalcidol was associated with a better survival rate (8). The aim of the present study was to assess the effect of alfacalcidol therapy on survival in a regional Japanese cohort of prevalent HD patients.

PATIENTS AND METHODS A prospective clinical study was conducted between January 2005 and December 2010. A total of 190 HD patients were recruited from among patients who had been routinely treated in the dialysis unit of the Hidaka Hospital for at least 6 months. HD patients, who had septicemia and severe illness, were excluded and transferred to another dialysis unit for intensive care. We examined data collected from the prevalent 190 HD patients having a baseline value of demographic and laboratory results and record of drug administration. The underlying renal diseases 248

Received August 2011; revised November 2011. Address correspondence and reprint requests to Dr Kosaku Nitta, Professor, Department of Medicine, Kidney Center, Tokyo Womens Medical University, 8-1 Kawada-cho, Shinjuku-ku,Tokyo 162-8666, Japan. Tel: +81 3 3353 8111, Fax: +81 3 5379 4360. Email: knitta@kc.twmu.ac.jp

Vitamin D and Mortality in Hemodialysis were diabetic nephropathy (N = 60) and nephropathy of non-diabetic origin (N = 130). The Institutional Research Ethics Committee approved the study protocol, and all patients signed an informed consent form. HD with bicarbonate dialysate was performed three times weekly (4 h/day). The potassium concentration of the dialysate was 2.0 mEq/L, and its calcium concentration was 3.0 mEq/L. Based on the medications at entry, the 190 patients were divided into two groups, according to whether or not treatment regimen at entry included alfacalcidol therapy. Medical records were carefully checked for prescriptions of antihypertensive drugs, lipidlowering agents and weekly doses of calcium carbonate (CaCO3) and alfacalcidol. Alfacalcidol was administered when serum calcium was less than 8.5 mg/dL even after titration with CaCO3 and the doses of alfacalcidol and sevelamer were not changed during the follow-up period. The patients in the two groups were compared according to their baseline characteristics and treatment. None had a history of parathyroidectomy before entry into the study. The primary outcome was all-cause mortality and cardiovascular mortality during a 5-year follow-up period. This study was conducted in compliance with the Declaration of Helsinki. Blood pressure with a brachial sphygmomanometer was recorded three times after the subject had rested in the supine position for at least 10 min, and the average value of the three measurements was adopted. Blood was collected at entry to measure
TABLE 1.

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routine laboratory parameters, including hemoglobin concentration, serum levels of urea nitrogen, creatinine, albumin, calcium, phosphorus, total cholesterol, HDL-cholesterol, triglyceride, CRP, and alkaline phosphatase. The non-HDL-cholesterol was calculated by subtracting the HDL-cholesterol from the total cholesterol. Mean values of three measurements during the 3 months before the start of this study were used for analysis. Continuous variables are reported as means SD, and categorical variables are presented as numbers and percentages. The differences between group means were tested for statistical signicance by analysis of variance or the c2 test (categorical variables), as appropriate. Survival curves were plotted by the KaplanMeier method and assessed by the log-rank test. Prognostic variables for survival were identied by univariate and multivariate analyses. Multivariate stepwise methods included variables with P-value less than 0.2 by univariate analyses. Differences with P-values <0.05 were considered statistically signicant. The statistical analyses were performed by using the Stat View 5 software program (SAS Institute Inc., Cary, NC, USA) for Windows personal computers. RESULTS The clinical characteristics of the users and nonusers of alfacalcidol are summarized in Table 1. Alfacalcidol therapy was performed in 89 (46.8%) of the

Baseline characteristics of the users and non-users of alfacalcidol

All Users (N = 89) 60.9 11.0 60 (67.4) 108.4 102.7 21.1 2.8 27 (30.3) 138.4 23.1 79.7 11.5 58.8 16.7 11.1 2.8 8.8 0.8 6.0 1.2 213.8 117.8 153.0 34.6 44.2 12.3 108.8 34.7 105.1 62.8 3.8 0.3 245.0 80.6 0.3 0.8 10.1 1.0 65 (73.0) 17 (19.1) 17.4 8.7 5.2 1.8 Non-users (N = 101) 61.0 12.5 57 (56.4) 101.9 85.4 21.8 4.8 33 (32.7) 136.0 24.9 77.9 13.4 58.1 16.2 11.0 3.2 8.8 0.9 6.1 1.2 245.1 160.8 151.7 34.6 42.8 13.3 108.9 31.9 117.0 64.8 3.7 0.3 287.1 112.2 0.4 0.6 10.3 1.0 66 (65.4) 23 (22.8) 18.3 11.1 0 P-value 0.9330 0.1364 0.6350 0.2369 0.7565 0.4832 0.3192 0.7911 0.6835 0.6854 0.5524 0.1325 0.7975 0.4693 0.9899 0.2016 0.1258 0.0038 0.7377 0.0909 0.2532 0.5949 0.5409

Age (years) Male (%) Dialysis vintage (months) Body mass index (kg/m2) Diabetes (%) Systolic blood pressure (mm Hg) Diastolic blood pressure (mm Hg) Pulse pressure (mm Hg) Creatinine (mg/dL) Calcium (mg/dL) Phosphorous (mg/dL) Intact parathyroid hormone (pg/mL) Total cholesterol (mg/dL) HDL cholesterol (mg/dL) Non-HDL cholesterol (mg/dL) Triglycerides (mg/dL) Albumin (g/dL) Alkaline phosphatase (U/L) C-reactive protein (mg/dL) Hemoglobin (g/dL) Anti-hypertensive drugs (%) Lipid-lowering agents (%) CaCO3 (g/week) Alfacalcidol (mg/week)

61.0 11.8 117 (61.6) 104.9 93.7 21.5 4.0 60 (31.6) 137.1 24.0 78.7 12.6 58.4 16.4 11.1 3.0 8.8 0.9 6.1 1.2 230.4 142.8 152.3 34.5 43.5 12.8 108.9 33.1 111.5 64.0 3.8 0.3 267.3 100.7 0.4 0.7 10.2 1.0 131 (68.9) 40 (21.1) 17.9 10.0

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M Ogawa et al.

190 patients, and the mean dose was 5.2 1.8 mg/ week. There was no signicant difference between the users and non-users in demographic or clinical parameters, including their serum calcium, phosphorus, or intact PTH levels, or in regard to prescription of phosphate binders, anti-hypertensive drugs, or lipid-lowering agents. Follow-up was completed in December, 2010, and during the follow-up period, 38 deaths were recorded including 19 deaths from cardiovascular events. The dates and causes of death were obtained by reviewing the hospital record. The 19 deaths from cardiovascular events were attributable to acute myocardial infarction (N = 7), congestive heart failure (N = 6), stroke (N = 3), and peripheral artery disease (N = 3). Non-cardiovascular causes of death were sepsis in ve patients, pneumonia in three patients, cancer in two patients, peritonitis in one patient, pulmonary hypertension in one patient, malnutrition in one patient and unknown origin in six patients. The mean follow-up period was 58 22 months. According to the KaplanMeier analysis, the alfacalcidol users had a signicant lower rate of all-cause mortality (Fig. 1) and cardiovascular mortality (Fig. 2) than the nonusers. The mean daily dose of alfacalcidol was 0.57 mg and was not changed during the follow-up period. During the 3 months before the start of this study, four patients were administered 1.0 mg of alfacalcidol for the treatment of secondary hyperparathyroidism. The death rate in non-users was signicantly higher than those in the low-dose group (less than 6 mg/ week) (P = 0.0052). In addition, there was no signicant difference in death rate between the non-user group and the high-dose group (more than 6 mg/ week) (P = 0.1629). The univariate Cox proportional hazards model was used to identify predictors of all-cause mortality (Table 2) and cardiovascular mortality (Table 3),

FIG. 2. KaplanMeier analysis of association of use of alfacalcidol and cardiovascular mortality in chronic hemodialysis patients.

and the results showed a signicant association between alfacalcidol therapy and all-cause mortality and cardiovascular mortality. Other signicant univariate predictors of all-cause mortality were age, dialysis vintage, pulse pressure, and the serum creatinine, non-HDL-cholesterol, triglycerides, albumin, alkaline phosphatase, and CRP levels. Age, presence of diabetes, systolic blood pressure, pulse pressure, and serum creatinine levels were identied as univarite predictors of cardiovascular mortality. The multivariate Cox proportional hazards model was used to identify predictors of all-cause mortality (Table 4) and cardiovascular mortality (Table 5). In addition to alfacalcidol therapy (HR=0.347 [0.155 0.714]; P = 0.0035), serum CRP levels (HR= 1.746 [1.1842.442]; P = 0.0071) and non-HDL-cholesterol levels (HR=1.012 [1.0011.022]; P = 0.0267) were identied as independent predictors of all-cause mortality, whereas the presence of diabetes mellitus (HR=3.720 [1.18212.398]; P = 0.0246) was identied as an independent predictor of cardiovascular mortality. The benecial effect of alfacalcidol therapy on all-cause mortality and cardiovascular mortality remained signicant when the model included systolic blood pressure, pulse pressure, or non-HDL cholesterol. DISCUSSION The results of this study showed that alfacalcidol therapy was associated with a signicantly lower risk of all-cause mortality and cardiovascular mortality in our cohort of chronic HD patients. Whether active vitamin D treatment has a benecial or detrimental effect on the cardiovascular system and risk of mortality of HD patients has been a matter of controversy. The concern about a harmful
2012 The Authors Therapeutic Apheresis and Dialysis 2012 International Society for Apheresis

FIG. 1. KaplanMeier analysis of association of use of alfacalcidol and all-mortality in chronic hemodialysis patients.

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Vitamin D and Mortality in Hemodialysis

TABLE 2. Predictors of all-cause mortality by univariate Cox analysis
HR 1.037 0.903 0.996 1.019 1.773 1.012 0.996 1.028 0.861 0.844 0.851 1.001 1.007 0.986 1.010 1.005 0.278 1.003 1.635 0.838 1.284 1.895 1.001 0.361 95% CI 1.0081.068 0.4771.749 0.9921.000 0.9371.087 0.9153.358 0.9991.026 0.9711.022 1.0091.047 0.7770.956 0.5851.225 0.6361.121 0.9991.003 0.9981.016 0.9581.012 1.0011.018 1.0001.009 0.1070.754 1.0011.006 1.1692.130 0.6051.158 0.6452.779 0.9223.674 0.3614.154 0.1670.720 P-value 0.0124 0.7570 0.0387 0.6426 0.0882 0.0717 0.7522 0.0045 0.0052 0.3704 0.2572 0.3463 0.1049 0.2965 0.0379 0.0666 0.0124 0.0145 0.0066 0.2854 0.4898 0.0801 0.4560 0.0033

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Candidate variables Age (/1 year) Male (vs. female) Dialysis vintage (/1 months) Body mass index (/1 kg/m2) Diabetic (vs. Non-diabetic) Systolic blood pressure (/1 mm Hg) Diastolic blood pressure (/1 mm Hg) Pulse pressure (/1 mm Hg) Creatinine (/1 mg/dL) Calcium (/1 mg/dL) Phosphorous (/1 mg/dL) Intact-parathyroid hormone (/1 pg/mL) Total cholesterol (/1 mg/dL) HDL-cholesterol (/1 mg/dL) Non-HDL-cholesterol (/1 mg/dL) Triglycerides (/1 mg/dL) Albumin (/1 g/dL) Alkaline phosphatase (/1 U/L) C-reactive protein (/1 mg/dL) Hemoglobin (/1 g/dL) Anti-hypertensive drugs (vs. non users) Lipid-lowering agents (vs. non users) CaCO3 (vs. non users) Alfacalcidol (vs. non users)

effect of vitamin D is mainly based on the fact that high doses of vitamin D have been shown to increase vascular calcication in experimental animal models (9,10). On the other hand, low doses and more physiological doses of active vitamin D have been found to have a cardioprotective effect (11,12). We previously reported nding that low-dose oral vitamin D therapy protects HD patients from developing vascular calcication (13).
TABLE 3.

Observational studies have demonstrated the advantages of treatment of HD patients with active vitamin D in regard to cardiovascular mortality (8) and all-cause mortality (1416). Although oral active vitamin D therapy is widely prescribed, there have been few reports of studies that investigated the survival benet of treatment with oral active vitamin D in HD patients (8,17). In a study of 242 HD patients, Shoji et al. (8) reported that patients treated with

Predictors of cardiovascular mortality by univariate Cox analysis

HR 1.045 0.906 0.317 1.029 4.188 1.025 1.002 1.049 0.815 0.989 0.817 1.000 1.011 0.999 1.012 1.002 0.330 1.003 1.519 0.966 2.450 2.405 0.728 0.361 95% CI 1.0031.091 0.3672.342 0.9970.991 0.9151.119 1.68411.258 1.0061.046 0.9661.039 1.0221.078 0.7020.944 0.5871.691 0.5361.206 0.9971.003 0.9981.023 0.9621.033 0.9991.024 0.9941.009 0.0861.393 0.9991.006 0.8652.233 0.6101.513 0.81610.531 0.8955.981 0.2094.590 0.1170.945 P-value 0.0331 0.8330 0.3167 0.5957 0.0021 0.0107 0.9281 0.0004 0.0064 0.9680 0.3176 0.9138 0.0888 0.9656 0.0719 0.6348 0.1293 0.1496 0.1261 0.8805 0.1170 0.0795 0.6835 0.0375

Candidate variables Age (/1 year) Male (vs. female) Dialysis vintage (/1 months) Body mass index (/1 kg/m2) Diabetic (vs. Non-diabetic) Systolic blood pressure (/1 mm Hg) Diastolic blood pressure (/1 mm Hg) Pulse pressure (/1 mm Hg) Creatinine (/1 mg/dL) Calcium (/1 mg/dL) Phosphorous (/1 mg/dL) Intact-parathyroid hormone (/1 pg/mL) Total cholesterol (/1 mg/dL) HDL-cholesterol (/1 mg/dL) Non-HDL-cholesterol (/1 mg/dL) Triglycerides (/1 mg/dL) Albumin (/1 g/dL) Alkaline phosphatase (/1 U/L) C-reactive protein (/1 mg/dL) Hemoglobin (/1 g/dL) Anti-hypertensive drugs (vs. non users) Lipid-lowering agents (vs. non users) CaCO3 (vs. non users) Alfacalcidol (vs. non users)

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TABLE 4.
Multivariate Alfacalcidol (vs. non users) C-reactive protein (/1 mg/dL) Non-HDL-cholesterol (/1 mg/dL) Alkaline phosphatase (/1 U/L) Age (/1 year) Dialysis vintage (/1 months) Pulse pressure (/1 mm Hg) Creatinine (/1 mg/dL) Albumin (/1 g/dL)

M Ogawa et al.
Independent predictors of all-cause mortality by stepwise multivariate Cox analysis
HR 0.347 1.746 1.012 1.003 1.014 0.998 1.015 1.004 0.653 95% CI 0.1550.714 1.1842.442 1.0011.022 1.0001.005 0.9831.046 0.9921.002 0.9931.039 0.8641.168 0.1692.597 P-value 0.0035 0.0071 0.0267 0.0695 0.3850 0.3085 0.1897 0.9599 0.5417

alfacalcidol were at reduced risk of cardiovascular death according to an adjusted Cox model. NavesDiaz et al. (17) showed a signicant survival advantage of oral active vitamin D therapy that appeared to be independent of other potential risk factors and confounders, and the results of the present study are consistent with their ndings. A French group recently reported a similar efcacy of vitamin D therapy with either daily calcifediol (1050 mg/day) (18) or monthly cholecalciferol (100 000 U) (19). They reported no evident toxicity, a small decrease in serum PTH levels, and correction of vitamin D deciency in more than 80% of the cases. The positive results in regard to all-cause mortality suggest that the benecial effect of active vitamin D is greater than its effect on calcium-phosphorus metabolism. Several experimental studies have recently demonstrated an important role of active vitamin D in suppressing cell growth and regulating immune response (20,21). Moreover, nutritional and epidemiological evidence has linked abnormalities in the vitamin D metabolism to increased susceptibility to infection (22). The present study identied serum CRP and non-HDL-cholesterol levels as well as alfacalcidol therapy as independent predictors of allcause mortality. Inammation and elevated serum non-HDL-cholesterol levels have been found to be risk factors of atherosclerosis in HD patients. It is likely that active vitamin D affects arterial cells and plays a role against infectious status in HD patients (23).
TABLE 5.
Multivariate Diabetic (vs. Non-diabetic) Alfacalcidol (vs. non users) Age (/1 year) Systolic blood pressure (/1 mm Hg) Pulse pressure (/1 mm Hg) Creatinine (/1 mg/dL)

The benet of oral vitamin D therapy in regard to the cardiovascular system remains unclear. It is well known that high-doses of active vitamin D increase serum calcium and phosphorus levels and suppresses serum PTH levels. On the other hand, physiological doses of active vitamin D have been shown to have protective effects by reducing the inammatory response to cardiovascular injury, myocardial cell hypertrophy and proliferation, and renin-angiotensin system activation (24). Some of the paradoxical effects of vitamin D can be explained by the differences between the doses of active vitamin D prescribed. High pharmacological doses may precipitate vascular calcication, whereas low doses may have a protective effect. The results of the present study showed that mean daily oral alfacalcidol doses below 1 mg had a signicant benet in reducing all-cause mortality and cardiovascular mortality in chronic HD patients, and these ndings are consistent with the results of a previous study (17). Naves-Diaz et al. (17) reported that a mean daily oral vitamin D dose below 0.25 mg was able to reduce the mortality rate by 53% in HD patients whose serum PTH levels were below 150 pg/ mL, independently of their serum calcium or phosphorus levels. Alfacalcidol is the most frequently used calcitriol analog in Japan, probably because of the different dosage forms that are available. A once daily dose of an oral preparation is the most common prescription. Daily administration of 0.25 mg is most frequently

Independent predictors of cardiovascular mortality by stepwise multivariate Cox analysis

HR 3.720 0.317 1.030 0.980 1.050 0.950 95% CI 1.18212.398 0.1010.839 0.9761.091 0.9351.029 0.9771.127 0.8021.129 P-value 0.0246 0.0198 0.2961 0.4186 0.1818 0.5518

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2012 The Authors Therapeutic Apheresis and Dialysis 2012 International Society for Apheresis

Vitamin D and Mortality in Hemodialysis prescribed. In view of the benecial effect of alfacalcidol therapy on HD patients who are decient in vitamin D, the dose prescribed seems to be important. However, measurement of serum 25(OH)D levels has not been regularly performed in Japan. Whether alfacalcidol has a benecial effect on mortality rate of HD patients is likely to depend on their serum 25(OH)D levels. Our study had the following limitations. First, the sample size was small. However, the prospective cohort design enabled prediction of mortality risk without changes in the alfacalcidol doses during a 5-year follow-up period. Second, only baseline parameters were recorded, and time-integrated parameters were not. Third, we did not measure serum 25(OH)D levels, and they may affect the benecial effect of alfacalcidol on mortality risk.

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CONCLUSION The results of the present study demonstrated that hemodialysis patients receiving low oral doses of active vitamin D had a survival advantage, and this benecial effect was seen even after adjustment for several confounders. However, only a randomized controlled trial can provide denitive proof of the benet of vitamin D therapy with an active vitamin D analog. REFERENCES
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7. Pecovnik-Balon B, Jakopin E, Bevc S et al. Vitamin D as a novel nontraditional risk factor for mortality in hemodialysis patients. Ther Apher Dial 2009;13:26872. 8. Shoji T, Shinohara K, Kimoto E et al. Lower risk for cardiovascular mortality in oral 1alpha-hydroxy vitamin D 3 users in a haemodialysis population. Nephrol Dial Transplant 2004;19: 17984. 9. Henley C, Colloton M, Cattley RC et al. 1,25-dihydroxyvitamin D3 but not cinacalcet HCl (Sensipar/Mimpara) treatment mediates aortic calcication in a rat model of secondary hyperparathyroidism. Nephrol Dial Transplant 2005;20: 13707. 10. Lopez I, Aguilera-Tejero E, Mendoza FJ et al. Calcimimetic R-568 decreases extraosseous calcications in uremic rats treated with calcitriol. J Am Soc Nephrol 2006;17:795804. 11. Wu J, Garami M, Cheng T et al. 1,25(OH)2 vitamin D3 and retinoic acid antagonize endothelin-stimulated hypertrophy of neonatal rat cardiac myocytes. J Clin Invest 1996;97:157788. 12. OConnell TD, Berry JE, Jarvis AK et al. 1,25-dihydroxyvitamin D3 regulation of cardiac myocyte proliferation and hypertrophy. Am J Physiol 1997;272(Pt 2):H17518. 13. Ogawa T, Ishida H, Akamatsu M et al. Relation of oral 1alphahydroxy vitamin D3 to the progression of aortic arch calcication in hemodialysis patients. Heart Vessels 2010;25:1 6. 14. Teng M, Wolf M, Lowrie E et al. Survival of patients undergoing hemodialysis with paricalcitol or calcitriol therapy. N Engl J Med 2003;349:44656. 15. Kalantar-Zadeh K, Kuwae N, Regidor DL et al. Survival predictability of time-varying indicators of bone disease in maintenance hemodialysis patients. Kidney Int 2006;70:77180. 16. Tentori F, Hunt WC, Stidley CA et al. Mortality risk among hemodialysis patients receiving different vitamin D analogs. Kidney Int 2006;70:185865. 17. Naves-Diaz M, Alvarez-Hernandez D, Passlick-Deetjen J et al. Oral active vitamin D is associated with improved survival in hemodialysis patients. Kidney Int 2008;74:10708. 18. Jean G, Terrat J-C, Vanel T et al. Daily oral 25-hydroxycholecalciferol supplementation for vitamin D deciency in haemodialysis patients: effects on mineral metabolism and bone markers. Nephrol Dial Transplant 2008;23:36706. 19. Jean G, Souberbielle JC, Chazot C. Monthly cholecalciferol administration in haemodialysis patients: a simple and efcient strategy for vitamin D supplementation. Nephrol Dial Transplant 2009;24:3799805. 20. Dusso AS, Brown AJ, Slatopolsky E. Vitamin D. Am J Physiol Renal Physiol 2005;289:F828. 21. Tangpricha V, Spina C, Yao M et al. Vitamin D deciency enhances the growth of MC-26 colon cancer xenografts in Balb/c mice. J Nutr 2005;135:23504. 22. Zittermann A. Vitamin D in preventive medicine: are we ignoring the evidence? Br J Nutr 2003;89:55272. 23. Gurlek A, Pittelkow MR, Kumar R. Modulation of growth factor/cytokine synthesis and signaling by 1alpha,25dihydroxyvitamin D 3: implications in cell growth and differentiation. Endocr Rev 2002;23:76386. 24. Levin A, Li YC. Vitamin D and its analogues: do they protect against cardiovascular disease in patients with kidney disease? Kidney Int 2005;68:197381.

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