From the Guidelines
No, an elevated PTH of 771 and calcium of 10.5 in a dialysis patient is not normal, but it is a common finding called secondary hyperparathyroidism. This condition occurs because damaged kidneys cannot properly activate vitamin D or remove phosphate, leading to high phosphate levels and low calcium, which stimulates the parathyroid glands to overproduce PTH. The target PTH range for dialysis patients is typically 150-300 pg/mL, so 771 is significantly elevated 1.
Causes and Treatment
Treatment usually involves controlling phosphate with phosphate binders (such as sevelamer, calcium acetate, or lanthanum carbonate) taken with meals, vitamin D analogs (calcitriol, paricalcitol, or doxercalciferol), and possibly calcimimetics like cinacalcet if PTH remains very high 1. The slightly elevated calcium (normal range typically 8.5-10.2 mg/dL) should be monitored closely, as it may limit some treatment options.
Monitoring and Management
Regular monitoring of calcium, phosphate, and PTH levels is essential, and medication adjustments should be made by a nephrologist familiar with managing mineral bone disorder in kidney disease 1. It is also important to note that surgical parathyroidectomy may be indicated in cases of severe hyperparathyroidism associated with hypercalcemia or hyperphosphatemia that cannot be controlled with medical therapy 1.
Key Considerations
Key considerations in the management of secondary hyperparathyroidism in dialysis patients include the use of calcium-based phosphate binders, vitamin D analogs, and calcimimetics, as well as the monitoring of calcium, phosphate, and PTH levels 1. The goal of treatment is to control PTH levels, prevent hypercalcemia and hyperphosphatemia, and maintain bone health.
From the FDA Drug Label
The average baseline serum iPTH was 701 pg/mL (range: 216 to 1933 pg/mL). The incidence of hypercalcemia (defined as two consecutive serum calcium values > 10.5 mg/dL) in patients treated with paricalcitol capsules was 6. 6% as compared to 0% for patients given placebo.
Elevated PTH and Calcium Levels in Stage Renal Disease Patient
- The patient's PTH level of 771 pg/mL is within the range of baseline serum iPTH levels (216 to 1933 pg/mL) observed in patients with CKD Stage 5 on HD or PD 2.
- The patient's calcium level of 10.5 mg/dL is at the threshold for hypercalcemia, which was observed in 6.6% of patients treated with paricalcitol capsules 2.
- Given the patient's stage renal disease and dialysis status, elevated PTH and calcium levels may be expected, but the specific values should be monitored and managed to prevent hypercalcemia and other complications 2, 3.
From the Research
Patient's Condition
- The patient has stage renal disease and is on dialysis.
- The patient's PTH level is elevated at 771.
- The patient's calcium level is 10.5.
Secondary Hyperparathyroidism in Dialysis Patients
- Secondary hyperparathyroidism is a common complication of chronic kidney disease, particularly in patients undergoing dialysis 4, 5, 6, 7.
- Elevated PTH levels can lead to hypercalcemia, hyperphosphatemia, and extraskeletal calcifications 5.
- Treatment of secondary hyperparathyroidism typically involves vitamin D analogs, such as paricalcitol or calcitriol, along with dietary phosphorus restriction and phosphate binding agents 4, 6, 7.
Normal Ranges for PTH and Calcium in Dialysis Patients
- The desired range for PTH levels in dialysis patients is typically between 100-250 pg/ml 5.
- Normal calcium levels in dialysis patients are typically between 8.5-10.5 mg/dl 5.
- The patient's PTH level of 771 is elevated, and the calcium level of 10.5 is at the upper limit of normal.
Management of Secondary Hyperparathyroidism
- Paricalcitol has been shown to be effective in suppressing elevated PTH levels in dialysis patients with minimal impact on calcium and phosphorus homeostasis 4, 6, 7.
- The treatment of secondary hyperparathyroidism should aim to maintain PTH levels within the desired range, while also controlling calcium and phosphorus levels 5, 6, 7.
- Regular monitoring of PTH, calcium, and phosphorus levels is necessary to adjust treatment and prevent complications 5, 6, 7.