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Background and objectives The calcimimetic cinacalcet reduced the risk of death or cardiovascular (CV) events in older, but not younger, patients with moderate to severe secondary hyperparathyroidism (HPT) who were receiving hemodialysis. To determine whether the lower risk in younger patients might be due to lower baseline CV risk and more frequent use of cointerventions that reduce parathyroid hormone (kidney transplantation, parathyroidectomy, and commercial cinacalcet use), this study examined the effects of cinacalcet in older ($65 years, n=1005) and younger (,65 years, n=2878) patients.Design, setting, participants, & measurements Evaluation of Cinacalcet HCl Therapy to Lower Cardiovascular Events (EVOLVE) was a global, multicenter, randomized placebo-controlled trial in 3883 prevalent patients on hemodialysis, whose outcomes included death, major CV events, and development of severe unremitting HPT. The age subgroup analysis was prespecified.Results Older patients had higher baseline prevalence of diabetes mellitus and CV comorbidity. Annualized rates of kidney transplantation and parathyroidectomy were .3-fold higher in younger relative to older patients and were more frequent in patients randomized to placebo. In older patients, the adjusted relative hazard (95% confidence interval) for the primary composite (CV) end point (cinacalcet versus placebo) was 0.70 (0.60 to 0.81); in younger patients, the relative hazard was 0.97 (0.86 to 1.09). Corresponding adjusted relative hazards for mortality were 0.68 (0.51 to 0.81) and 0.99 (0.86 to 1.13). Reduction in the risk of severe unremitting HPT was similar in both groups. ConclusionsIn the EVOLVE trial, cinacalcet decreased the risk of death and of major CV events in older, but not younger, patients with moderate to severe HPT who were receiving hemodialysis. Effect modification by age may be partly explained by differences in underlying CV risk and differential application of cointerventions that reduce parathyroid hormone.

Access-related infections are a leading cause of morbidity and mortality among hemodialysis patients. Staphylococcus aureus bacteremia accounts for 25% of these episodes. Nissenson et al., found that 20.7% of the patients developing S. aureus bacteremia had infectious complications as well as hospital readmissions related to the S. aureus bacteremia. This retrospective analysis did not determine whether the S. aureus bacteremia was access related, nor how each episode was treated. We have prospectively collected a database of all access-related S. aureus bacteremia developing in our unit between 1/1/03 and 8/31/05, including the management of the access. Episodes of S. aureus bacteremia with an identifiable source other than the vascular access were excluded. Seventy-two episodes of S. aureus bacteremia were identified; 54 developed in patients using a catheter and 18 developed in patients using an arteriovenous graft/fistula. The mean age was 64+/-15 years, and 56% of the patients were Caucasian. All patients were treated with 4 weeks of antibiotics. A total of 6 (8%) deaths and 15 (20.8%) infectious complications related to the S. aureus bacteremia were identified. Infectious complications included endocarditis (4), metastatic infection (7), discitis (3), and a myocardial abscess (1). Seventeen (23.6%) of the patients were readmitted within 30 days of the episode of S. aureus bacteremia; 4 readmissions were related to the S. aureus bacteremia. Five of the 54 catheter patients who developed S. aureus bacteremia expired and 14 developed infectious complications despite the catheter being removed/exchanged in all but one patient. One of the arteriovenous graft patients who developed S. aureus bacteremia expired. We conclude that infectious complications from S. aureus bacteremia are common, as 23.6% of the patients in our study developed an infectious complication. Eight percent of the patients who developed S. aureus bacteremia expired. Strategies to avoid S. aureus bacteremia are needed.

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