problendoПроблемы ЭндокринологииProblems of Endocrinology0375-96602308-1430Endocrinology Research Centre10.14341/probl13167problendo-13167Research ArticleБолезни костной и жировой тканиBones & Adipose tissues diseasesПаттерн биохимических маркеров минеральных и костных нарушений у реципиентов почечного трансплантата: опыт одного центраPattern of biochemical markers of mineral and bone disorders in kidney transplant recipients: real-world datahttps://orcid.org/0000-0001-8497-0693ВатазинА. В.VatazinA. V.

Ватазин Андрей Владимирович - доктор медицинских наук, профессор.

Москва

Andrey V. Vatazin - MD, PhD, Professor.

Moscow

vatazin@yandex.ruhttps://orcid.org/0000-0003-3625-1824ПаршинаЕ. В.ParshinaE. V.

Паршина Екатерина Викторовна

109103, Санкт-Петербург, Университетская наб., д. 7/9

Ekaterina V. Parshina - MD.

7/9, Universitetskaya emb., 109103, Saint-Petersburg

e.parshina@spbu.ruhttps://orcid.org/0000-0003-4388-7759КантарияР. О.KantariaR. O.

Кантария Русудана Отаровна - кандидат медицинских наук.

Москва

Rusudana O. Kantaria - MD, PhD.

rusiko_k@mail.ruhttps://orcid.org/0000-0002-0881-0599СтепановВ. А.StepanovV. A.

Степанов Вадим Анатольевич - кандидат медицинских наук.

Москва

Vadim A. Stepanov - MD, PhD.

vedmak_@rambler.ruhttps://orcid.org/0000-0001-5405-7887ЗулькарнаевА. Б.ZulkarnaevA. B.

Зулькарнаев Алексей Батыргараевич - доктор медицинских наук, доцент.

Москва

Alexey B. Zulkarnaev - MD, PhD, Assistant Professor.

7059899@gmail.comМосковский областной научно-исследовательский клинический институт им. М.Ф. ВладимирскогоРоссияMoscow Regional Research and Clinical InstituteRussian FederationСанкт-Петербургский государственный университетРоссияSaint-Petersburg State University HospitalRussian Federation2023110520236924757Copyright © Ватазин А.В., Паршина Е.В., Кантария Р.О., Степанов В.А., Зулькарнаев А.Б., 20232023Ватазин А.В., Паршина Е.В., Кантария Р.О., Степанов В.А., Зулькарнаев А.Б.Vatazin A.V., Parshina E.V., Kantaria R.O., Stepanov V.A., Zulkarnaev A.B.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.probl-endojournals.ru/jour/article/view/13167АКТУАЛЬНОСТЬ

АКТУАЛЬНОСТЬ. На сегодняшний день крайне мало исследований, представляющих объективные данные о распространенности минеральных и костных нарушений (МКН) у реципиентов почечного трансплантата (ПТ) в России. ЦЕЛЬ. Провести скрининг, включающий определение основных лабораторных показателей МКН у пациентов, перенесших аллотрансплантацию трупной почки (АТП), а также оценить назначение сопроводительной терапии, направленной на коррекцию МКН при хронической болезни почек (МКН-ХБП).

МАТЕРИАЛЫ И МЕТОДЫ

МАТЕРИАЛЫ И МЕТОДЫ. В поперечное исследование были включены 236 пациентов, перенесших успешную трансплантацию почки. У всех пациентов определяли уровень интактного паратиреоидного гормона (ПТГ), общего кальция, фосфора, щелочной фосфатазы (ЩФ) сыворотки.

РЕЗУЛЬТАТЫ

РЕЗУЛЬТАТЫ. Лишь у 6,2% реципиентов ПТ наблюдались целевые уровни всех исследуемых лабораторных показателей МКН, при этом повышенный уровень ПТГ в сочетании с гиперкальциемией был отмечен почти у трети пациентов (31%). Целевой уровень ПТГ наблюдался у 13% реципиентов, 84% пациентов демонстрировали гиперпаратиреоз. Доли пациентов с целевым уровнем ПТГ не различались в группах реципиентов с сохранной и сниженной расчетной скоростью клубочковой фильтрации (рСКФ) (p=0,118). Гиперкальциемия наблюдалась у 29% реципиентов. Уровни неорганического фосфора сыворотки значительно различались в группах пациентов с разной рСКФ (p<0,0001), возрастая по мере снижения функции трансплантата. У 40,7% пациентов было отмечено повышение уровня ЩФ. В качестве сопутствующей терапии 123 пациента получали активный витамин D (альфакальцидол), 33 пациента — препарат неактивной формы витамина D (колекальциферол), 57 пациентов не получали лекарственной терапии МКН-ХБП. Уровень общего кальция сыворотки статистически значимо различался в этих группах (p=0,0006), наиболее высокий его уровень отмечался в группе терапии колекальциферолом. Доля пациентов с нормокальциемией в группе лечения колекальциферолом была наиболее низкой (χ2 р=0,0018).

ЗАКЛЮЧЕНИЕ

ЗАКЛЮЧЕНИЕ. Распространенность МКН у реципиентов ПТ очень высока. Применение альфакальцидола по сравнению с препаратами неактивной формы витамина D может быть более безопасным в отношении развития гиперкальциемии.

BACKGROUND

BACKGROUND: There is a lack of studies providing comprehensive data on the prevalence of mineral and bone disorders (MBD) laboratory abnormalities after kidney transplantation in Russia.

AIM

AIM: to obtain real-world data on the prevalence of the main mineral abnormalities among kidney transplant recipients and to revise their concomitant MBD therapy.

METHOD

METHOD: This cross-sectional study included 236 patients with successful kidney transplantation. Their serum intact parathyroid hormone (iPTH), total calcium (Ca), phosphorus (P), and alkaline phosphatase (ALP) levels were measured.

RESULTS

RESULTS: Only 6.2% of our cohort had all laboratory parameters within the target range, whereas persistent HPT along with hypercalcemia was noted in almost one third of the patients (31%). Normal iPTH levels were observed in 13% cases; 84% of the patients had hyperparathyroidism. The fraction of patients with target iPTH did not differ between the groups with normal and decreased estimated glomerular filtration rate (eGFR) (p=0.118). Hypercalcemia was observed in 29% cases. The serum P level varied significantly in groups with different eGFR (p<0.0001), increasing with declining graft function. Furthermore, 40.7% of patients had ALP above the target range. While 123 patients received active vitamin D (alfacalcidol), 33 received monotherapy with inactive vitamin D (cholecalciferol). The control group consisted of 57 medication-naïve patients. The serum total Ca level varied significantly between the groups (p=0.0006), being higher in patients supplemented with cholecalciferol. The fraction of patients with normocalcemia was lowest in the cholecalciferol group (chi-square, р=0.0018).

CONCLUSION

CONCLUSION: The prevalence of biochemical abnormalities after kidney transplantation is high. Alfacalcidol usage may be safer than using cholecalciferol to prevent hypercalcemia development.

трансплантация почкигиперпаратиреозпаратиреоидный гормонгиперкальциемиявитамин Dkidney transplantationhyperparathyroidismparathyroid hormonehypercalcemiavitamin DРабота выполнена по инициативе авторов без привлечения финансированияReferencesАндрусев А.М., Томилина Н.А., Перегудова Н.Г., Шинкарев М.Б. Заместительная почечная терапия терминальной хронической почечной недостаточности в Российской Федерации 2014–2018 гг. Отчет по данным Общероссийского Регистра заместительной почечной терапии Российского диализного общества // Нефрология и диализ. — 2020. — Т. 22. — №1. — С. 1-71. doi: https://doi.org/10.28996/2618-9801-2020-1suppl-1-71Andrusev AM, Tomilina NA, Peregudova NG, Shinkarev MB. Renal replacement therapy of terminal chronic renal failure in the Russian Federation 2014–2018. Report on the data of the All-Russian Register of renal replacement therapy of the Russian Dialysis Society. Nephrology and dialysis. 2020;22(1):1-71. (In Russ.). doi: https://doi.org/10.28996/2618-9801-2020-1suppl-1-71Wolfe RA, Ashby VB, Milford EL, et al. Comparison of Mortality in All Patients on Dialysis, Patients on Dialysis Awaiting Transplantation, and Recipients of a First Cadaveric Transplant. N Engl J Med. 1999;341(23):1725-1730. doi: https://doi.org/10.1056/NEJM199912023412303Wolfe RA, Ashby VB, Milford EL, et al. Comparison of Mortality in All Patients on Dialysis, Patients on Dialysis Awaiting Transplantation, and Recipients of a First Cadaveric Transplant. N Engl J Med. 1999;341(23):1725-1730. doi: https://doi.org/10.1056/NEJM199912023412303Huffer WE, Kuzela D, Popovtzer MM, Starzl TE. Metabolic bone disease in chronic renal failure. II. Renal transplant patients. Am J Pathol. 1975;78(3):385-400.Huffer WE, Kuzela D, Popovtzer MM, Starzl TE. Metabolic bone disease in chronic renal failure. II. Renal transplant patients. Am J Pathol. 1975;78(3):385-400.Nielsen HE, Christensen MS, Melsen F, Torring S. Bone disease, hypophosphatemia and hyperparathyroidism after renal transplantation. Adv Exp Med Biol. 1977;(81):603-610. doi: https://doi.org/10.1007/978-1-4613-4217-5_58Nielsen HE, Christensen MS, Melsen F, Torring S. Bone disease, hypophosphatemia and hyperparathyroidism after renal transplantation. Adv Exp Med Biol. 1977;(81):603-610. doi: https://doi.org/10.1007/978-1-4613-4217-5_58Bleskestad I, Bergrem H, Leivestad T, et al. Parathyroid hormone and clinical outcome in kidney transplant patients with optimal transplant function. Clin Transplant. 2014;28(4):479-486. doi: https://doi.org/10.1111/ctr.12341Bleskestad I, Bergrem H, Leivestad T, et al. Parathyroid hormone and clinical outcome in kidney transplant patients with optimal transplant function. Clin Transplant. 2014;28(4):479-486. doi: https://doi.org/10.1111/ctr.12341Prakobsuk S, Sirilak S, Vipattawat K, et al. Hyperparathyroidism and increased fractional excretion of phosphate predict allograft loss in long-term kidney transplant recipients. Clin Exp Nephrol. 2016;21(5):926-931. doi: https://doi.org/10.1007/s10157-016-1370-9Prakobsuk S, Sirilak S, Vipattawat K, et al. Hyperparathyroidism and increased fractional excretion of phosphate predict allograft loss in long-term kidney transplant recipients. Clin Exp Nephrol. 2016;21(5):926-931. doi: https://doi.org/10.1007/s10157-016-1370-9Nielsen HE, Christensen MS, Meisen F, Tørring S. Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Update Work Group. KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder (CKD-MBD). Kidney Int Suppl. 2017;7(3):e1. doi: https://doi.org/10.1016/j.kisu.2017.10.001Nielsen HE, Christensen MS, Meisen F, Tørring S. Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Update Work Group. KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder (CKD-MBD). Kidney Int Suppl. 2017;7(3):e1. doi: https://doi.org/10.1016/j.kisu.2017.10.001Nephro.ru [Интернет]. Профессиональная организация: Общественная общероссийская организация «Российское диализное общество». Национальные клинические рекомендации: минеральные и костные нарушения при хронической болезни почек. 2015. Доступно по: http://www.nephro.ru/content/files/recomendations/ckdmbdNationalGuidelines.pdf. Ссылка активна на 01.03.2023.Nephro.ru [Интернет]. Professional association: Russian public association «Russian dialysis society». National clinical guidelines on CKD-MBD. 2015. (In Russ.). Доступно по: http://www.nephro.ru/content/files/recomendations/ckdmbdNationalGuidelines.pdf. Ссылка активна на 01.03.2023.Evenepoel P, Claes K, Kuypers D, et al. Natural history of parathyroid function and calcium metabolism after kidney transplantation: a single-centre study. Nephrol Dial Transplant. 2004;19(5):1281-1287. doi: https://doi.org/10.1093/ndt/gfh128Evenepoel P, Claes K, Kuypers D, et al. Natural history of parathyroid function and calcium metabolism after kidney transplantation: a single-centre study. Nephrol Dial Transplant. 2004;19(5):1281-1287. doi: https://doi.org/10.1093/ndt/gfh128Nielsen HE, Christensen MS, Meisen F, Tørring S. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl. 2013;3(1):1-150. doi: https://doi.org/10.1038/kisup.2012.73Nielsen HE, Christensen MS, Meisen F, Tørring S. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl. 2013;3(1):1-150. doi: https://doi.org/10.1038/kisup.2012.73Benjamini Y, Krieger AM, Yekutieli D. Adaptive linear step-up procedures that control the false discovery rate. Biometrika. 2006;93(3):491-507. doi: https://doi.org/10.1093/biomet/93.3.491Benjamini Y, Krieger AM, Yekutieli D. Adaptive linear step-up procedures that control the false discovery rate. Biometrika. 2006;93(3):491-507. doi: https://doi.org/10.1093/biomet/93.3.491Setterberg L, Sandberg J, Elinder C-G, Nordenstrom J. Bone demineralization after renal transplantation: contribution of secondary hyperparathyroidism manifested by hypercalcaemia. Nephrol Dial Transplant. 1996;11(9):1825-1828. doi: https://doi.org/10.1093/oxfordjournals.ndt.a027676Setterberg L, Sandberg J, Elinder C-G, Nordenstrom J. Bone demineralization after renal transplantation: contribution of secondary hyperparathyroidism manifested by hypercalcaemia. Nephrol Dial Transplant. 1996;11(9):1825-1828. doi: https://doi.org/10.1093/oxfordjournals.ndt.a027676Perrin P, Caillard S, Javier R, et al. Persistent hyperparathyroidism is a major risk factor for fractures in the five years after kidney transplantation. Am J Transplant. 2013;13(10):2653-2663. doi: https://doi.org/10.1111/ajt.12425Perrin P, Caillard S, Javier R, et al. Persistent hyperparathyroidism is a major risk factor for fractures in the five years after kidney transplantation. Am J Transplant. 2013;13(10):2653-2663. doi: https://doi.org/10.1111/ajt.12425Evenepoel P. Recovery versus persistence of disordered mineral metabolism in kidney transplant recipients. Semin Nephrol. 2013;33(2):191-203. doi: https://doi.org/10.1016/j.semnephrol.2012.12.019Evenepoel P. Recovery versus persistence of disordered mineral metabolism in kidney transplant recipients. Semin Nephrol. 2013;33(2):191-203. doi: https://doi.org/10.1016/j.semnephrol.2012.12.019Bleskestad I, Bergrem H, Leivestad T, Gøransson L. Intact parathyroid hormone levels in renal transplant patients with normal transplant function. Clin Transplant. 2011;25(5):E566-E570. doi: https://doi.org/10.1111/j.1399-0012.2011.01515.xBleskestad I, Bergrem H, Leivestad T, Gøransson L. Intact parathyroid hormone levels in renal transplant patients with normal transplant function. Clin Transplant. 2011;25(5):E566-E570. doi: https://doi.org/10.1111/j.1399-0012.2011.01515.xНовокшонов К.Ю., Карелина Ю.В., Земченков А.Ю., и др. Результаты скрининга на маркеры минеральных и костных нарушений при хронической болезни почек среди диализных пациентов Северо-Западного федерального округа // Нефрология. — 2016. — Т. 20. — №1. — С. 36-50.Novokshonоv KY, Karelina YV, Zemchenkov AY, et al. Chronic kidney disease mineral and bone disorder markers in screening study among dialysis patients in North-West federal region of Russia. Nefrologia. 2016;20(1):36-50. (In Russ.).Lehmann G, Ott U, Stein G, et al. Renal osteodystrophy after successful renal transplantation: a histomorphometric analysis in 57 patients. Transplant Proc. 2007;39(10):3153-3158. doi: https://doi.org/10.1016/j.transproceed.2007.10.001Lehmann G, Ott U, Stein G, et al. Renal osteodystrophy after successful renal transplantation: a histomorphometric analysis in 57 patients. Transplant Proc. 2007;39(10):3153-3158. doi: https://doi.org/10.1016/j.transproceed.2007.10.001van Londen M, Aarts B, Deetman P, et al. Post-transplant hypophosphatemia and the risk of death-censored graft failure and mortality after kidney transplantation. Clin J Am Soc Nephrol. 2017;12(8):1301-1310. doi: https://doi.org/10.2215/cjn.10270916van Londen M, Aarts B, Deetman P, et al. Post-transplant hypophosphatemia and the risk of death-censored graft failure and mortality after kidney transplantation. Clin J Am Soc Nephrol. 2017;12(8):1301-1310. doi: https://doi.org/10.2215/cjn.10270916Baia L, Heilberg I, Navis G, de Borst M. Phosphate and FGF-23 homeostasis after kidney transplantation. Nat Rev Nephrol. 2015;11(11):656-666. doi: https://doi.org/10.1038/nrneph.2015.153Baia L, Heilberg I, Navis G, de Borst M. Phosphate and FGF-23 homeostasis after kidney transplantation. Nat Rev Nephrol. 2015;11(11):656-666. doi: https://doi.org/10.1038/nrneph.2015.153Loffing J, Lötscher M, Kaissling B, et al. Renal Na/H exchanger NHE-3 and Na-PO4 cotransporter NaPi-2 protein expression in glucocorticoid excess and deficient states. J Am Soc Nephrol. 1998;9(9):1560-1567. doi: https://doi.org/10.1681/ASN.V991560Loffing J, Lötscher M, Kaissling B, et al. Renal Na/H exchanger NHE-3 and Na-PO4 cotransporter NaPi-2 protein expression in glucocorticoid excess and deficient states. J Am Soc Nephrol. 1998;9(9):1560-1567. doi: https://doi.org/10.1681/ASN.V991560Borowitz SM, Granrud GS. Glucocorticoids inhibit intestinal phosphate absorption in developing rabbits. J Nutr. 1992;122(6):1273-1279. doi: https://doi.org/10.1093/jn/122.6.1273Borowitz SM, Granrud GS. Glucocorticoids inhibit intestinal phosphate absorption in developing rabbits. J Nutr. 1992;122(6):1273-1279. doi: https://doi.org/10.1093/jn/122.6.1273Haller M, Amatschek S, Wilflingseder J, et al. Sirolimus induced phosphaturia is not caused by inhibition of renal apical sodium phosphate cotransporters. PLoS One. 2012;7(7):e39229. doi: https://doi.org/10.1371/journal.pone.0039229Haller M, Amatschek S, Wilflingseder J, et al. Sirolimus induced phosphaturia is not caused by inhibition of renal apical sodium phosphate cotransporters. PLoS One. 2012;7(7):e39229. doi: https://doi.org/10.1371/journal.pone.0039229Schwarz C, Böhmig G, Steininger R, et al. Impaired phosphate handling of renal allografts is aggravated under rapamycin‐based immunosuppression. Nephrol Dial Transplant. 2001;16(2):378-382. doi: https://doi.org/10.1093/ndt/16.2.378Schwarz C, Böhmig G, Steininger R, et al. Impaired phosphate handling of renal allografts is aggravated under rapamycin‐based immunosuppression. Nephrol Dial Transplant. 2001;16(2):378-382. doi: https://doi.org/10.1093/ndt/16.2.378Kempe D, Dermaku-Sopjani M, Frohlich H, et al. Rapamycin-induced phosphaturia. Nephrol Dial Transplant. 2010;25(9):2938-2944. doi: https://doi.org/10.1093/ndt/gfq172Kempe D, Dermaku-Sopjani M, Frohlich H, et al. Rapamycin-induced phosphaturia. Nephrol Dial Transplant. 2010;25(9):2938-2944. doi: https://doi.org/10.1093/ndt/gfq172Grignani G, Palmerini E, Ferraresi V, et al. Sorafenib and everolimus for patients with unresectable high-grade osteosarcoma progressing after standard treatment: a non-randomised phase 2 clinical trial. Lancet Oncol. 2015;16(1):98-107. doi: https://doi.org/10.1016/S1470-2045(14)71136-2Grignani G, Palmerini E, Ferraresi V, et al. Sorafenib and everolimus for patients with unresectable high-grade osteosarcoma progressing after standard treatment: a non-randomised phase 2 clinical trial. Lancet Oncol. 2015;16(1):98-107. doi: https://doi.org/10.1016/S1470-2045(14)71136-2Bouquegneau A, Salam S, Delanaye P, et al. Bone disease after kidney transplantation. Clin J Am Soc Nephrol. 2016;11(7):1282-1296. doi: https://doi.org/10.2215/cjn.11371015Bouquegneau A, Salam S, Delanaye P, et al. Bone disease after kidney transplantation. Clin J Am Soc Nephrol. 2016;11(7):1282-1296. doi: https://doi.org/10.2215/cjn.11371015Kanaan N, Claes K, Devogelaer J, et al. Fibroblast growth factor-23 and parathyroid hormone are associated with post-transplant bone mineral density loss. Clin J Am Soc Nephrol. 2010;5(10):1887-1892. doi: https://doi.org/10.2215/cjn.00950110Kanaan N, Claes K, Devogelaer J, et al. Fibroblast growth factor-23 and parathyroid hormone are associated with post-transplant bone mineral density loss. Clin J Am Soc Nephrol. 2010;5(10):1887-1892. doi: https://doi.org/10.2215/cjn.00950110Evenepoel P, Claes K, Meijers B, et al. Bone mineral density, bone turnover markers, and incident fractures in de novo kidney transplant recipients. Kidney Int. 2019;95(6):1461-1470. doi: https://doi.org/10.1016/j.kint.2018.12.024Evenepoel P, Claes K, Meijers B, et al. Bone mineral density, bone turnover markers, and incident fractures in de novo kidney transplant recipients. Kidney Int. 2019;95(6):1461-1470. doi: https://doi.org/10.1016/j.kint.2018.12.024Jeon H, Kim Y, Park S, et al. Association of serum phosphorus concentration with mortality and graft failure among kidney transplant recipients. Clin J Am Soc Nephrol. 2017;12(4):653-662. doi: https://doi.org/10.2215/cjn.07090716Jeon H, Kim Y, Park S, et al. Association of serum phosphorus concentration with mortality and graft failure among kidney transplant recipients. Clin J Am Soc Nephrol. 2017;12(4):653-662. doi: https://doi.org/10.2215/cjn.07090716Nakai K, Mitsuiki K, Kuroki Y, et al. Relative hypophosphatemia early after transplantation is a predictor of good kidney graft function. Clin Exp Nephrol. 2019;23(9):1161-1168. doi: https://doi.org/10.1007/s10157-019-01756-zNakai K, Mitsuiki K, Kuroki Y, et al. Relative hypophosphatemia early after transplantation is a predictor of good kidney graft function. Clin Exp Nephrol. 2019;23(9):1161-1168. doi: https://doi.org/10.1007/s10157-019-01756-zConnolly G, Cunningham R, McNamee P, et al. Elevated serum phosphate predicts mortality in renal transplant recipients. Transplantation. 2009;87(7):1040-1044. doi: https://doi.org/10.1097/tp.0b013e31819cd122Connolly G, Cunningham R, McNamee P, et al. Elevated serum phosphate predicts mortality in renal transplant recipients. Transplantation. 2009;87(7):1040-1044. doi: https://doi.org/10.1097/tp.0b013e31819cd122Merhi B, Shireman T, Carpenter M, et al. Serum phosphorus and risk of cardiovascular disease, all-cause mortality, or graft failure in kidney transplant recipients: an ancillary study of the FAVORIT trial cohort. Am J Kidney Dis. 2017;70(3):377-385. doi: https://doi.org/10.1053/j.ajkd.2017.04.014Merhi B, Shireman T, Carpenter M, et al. Serum phosphorus and risk of cardiovascular disease, all-cause mortality, or graft failure in kidney transplant recipients: an ancillary study of the FAVORIT trial cohort. Am J Kidney Dis. 2017;70(3):377-385. doi: https://doi.org/10.1053/j.ajkd.2017.04.014Pieper A, Buhle F, Bauer S, et al. The effect of sevelamer on the pharmacokinetics of cyclosporin A and mycophenolate mofetil after renal transplantation. Nephrol Dial Transplant. 2004;19(10):2630-2633. doi: https://doi.org/10.1093/ndt/gfh446Pieper A, Buhle F, Bauer S, et al. The effect of sevelamer on the pharmacokinetics of cyclosporin A and mycophenolate mofetil after renal transplantation. Nephrol Dial Transplant. 2004;19(10):2630-2633. doi: https://doi.org/10.1093/ndt/gfh446Alagoz S, Trabulus S. Long-term evaluation of mineral metabolism after kidney transplantation. Transplant Proc. 2019;51(7):2330-2333. doi: https://doi.org/10.1016/j.transproceed.2019.01.181Alagoz S, Trabulus S. Long-term evaluation of mineral metabolism after kidney transplantation. Transplant Proc. 2019;51(7):2330-2333. doi: https://doi.org/10.1016/j.transproceed.2019.01.181Delos Santos R, Rossi A, Coyne D, Maw T. Management of post-transplant hyperparathyroidism and bone disease. Drugs. 2019;79(5):501-513. doi: https://doi.org/10.1007/s40265-019-01074-4Delos Santos R, Rossi A, Coyne D, Maw T. Management of post-transplant hyperparathyroidism and bone disease. Drugs. 2019;79(5):501-513. doi: https://doi.org/10.1007/s40265-019-01074-4Keyzer C, Riphagen I, Joosten M, et al. Associations of 25(OH) and 1,25(OH)2 vitamin D with long-term outcomes in stable renal transplant recipients. J Clin Endocrinol Metab. 2015;100(1):81-89. doi: https://doi.org/10.1210/jc.2014-3012Keyzer C, Riphagen I, Joosten M, et al. Associations of 25(OH) and 1,25(OH)2 vitamin D with long-term outcomes in stable renal transplant recipients. J Clin Endocrinol Metab. 2015;100(1):81-89. doi: https://doi.org/10.1210/jc.2014-3012Messa P, Regalia A, Alfieri C. Nutritional vitamin D in renal transplant patients: speculations and reality. Nutrients. 2017;9(6):550. doi: https://doi.org/10.3390/nu9060550Messa P, Regalia A, Alfieri C. Nutritional vitamin D in renal transplant patients: speculations and reality. Nutrients. 2017;9(6):550. doi: https://doi.org/10.3390/nu9060550Cianciolo G, Galassi A, Capelli I, et al. Vitamin D in kidney transplant recipients: mechanisms and therapy. Am J Nephrol. 2016;43(6):397-407. doi: https://doi.org/10.1159/000446863Cianciolo G, Galassi A, Capelli I, et al. Vitamin D in kidney transplant recipients: mechanisms and therapy. Am J Nephrol. 2016;43(6):397-407. doi: https://doi.org/10.1159/000446863

The authors declare that there are no conflicts of interest present.