How is hyperparathyroidism related to renal (Kidney) failure typically managed?

From the Guidelines

Hyperparathyroidism related to renal failure is typically managed by a nephrologist, in collaboration with other healthcare professionals such as endocrinologists, surgeons, and dietitians. The management of hyperparathyroidism in renal failure (secondary hyperparathyroidism) focuses on controlling phosphate levels, normalizing calcium, and suppressing parathyroid hormone (PTH) production. The first-line approach includes:

• Dietary phosphate restriction (800-1000 mg/day)
• Phosphate binders such as calcium acetate (667 mg with meals), sevelamer (800-1600 mg with meals), or lanthanum carbonate (500-1000 mg with meals)
• Vitamin D analogs like calcitriol (0.25-1 mcg daily) or paricalcitol (1-5 mcg three times weekly) to suppress PTH secretion. For patients with persistently elevated PTH despite these measures, cinacalcet (starting at 30 mg daily, titrated up to 180 mg if needed) directly reduces PTH by increasing the sensitivity of calcium-sensing receptors 1. Regular monitoring of calcium, phosphate, and PTH levels is essential, with target PTH levels typically 2-9 times the upper limit of normal for dialysis patients. In severe cases unresponsive to medical therapy, parathyroidectomy may be necessary, as indicated by studies such as those published in the American Journal of Kidney Diseases 1. This comprehensive approach addresses the mineral metabolism disturbances that occur when failing kidneys cannot properly excrete phosphate or activate vitamin D, which triggers excessive PTH secretion as a compensatory mechanism. Key considerations in the management of hyperparathyroidism in renal failure include:
• Avoiding hypercalcemia, which can be harmful in all stages of chronic kidney disease (CKD) 1
• Using calcium-based phosphate binders judiciously, due to the risk of hypercalcemia 1
• Considering the use of calcimimetics, calcitriol, and vitamin D analogues as first-line options in patients receiving dialysis 1. Overall, the management of hyperparathyroidism in renal failure requires a multidisciplinary approach, with careful attention to mineral metabolism and regular monitoring of relevant laboratory parameters.

From the FDA Drug Label

The recommended starting oral dose of cinacalcet tablets is 30 mg once daily. Serum calcium and serum phosphorus should be measured within 1 week and intact parathyroid hormone (iPTH) should be measured 1 to 4 weeks after initiation or dose adjustment of cinacalcet tablets [see Dosage and Administration (2. 3)]. Cinacalcet tablets should be titrated no more frequently than every 2 to 4 weeks through sequential doses of 30,60,90,120, and 180 mg once daily to target iPTH levels of 150 to 300 pg/mL.

Nephrologists typically manage hyperparathyroidism related to renal (kidney) failure, often in collaboration with:

• Endocrinologists
• Primary care physicians Key aspects of management include:
• Medications like cinacalcet 2
• Monitoring of serum calcium and phosphorus levels
• Adjustment of vitamin D and phosphate binders as needed 2

From the Research

Management of Hyperparathyroidism Related to Renal Failure

Hyperparathyroidism related to renal failure is typically managed by a multidisciplinary team of healthcare professionals, including:

• Nephrologists
• Endocrine surgeons
• Radiologists

Medical Treatment

Medical treatment for hyperparathyroidism related to renal failure consists of:

• Supplying vitamin D and reducing phosphate intake 3
• Adding calcimimetics in later stages 3
• Using phosphate binders and vitamin D to control hyperphosphatemia and secondary hyperparathyroidism 4, 5
• Optimizing calcium and vitamin D intake 6
• Using antiresorptive therapy for skeletal protection in patients with an increased fracture risk 6
• Using cinacalcet, a calcimimetic agent, to lower serum calcium and PTH levels 6, 5

Surgical Treatment

Surgical treatment, such as parathyroidectomy, is considered when medical therapy cannot control the hyperparathyroidism 3, 4, 7

• Parathyroidectomy is indicated only when conservative treatment options fail 7
• Subtotal or total parathyroidectomy with autotransplantation are recognized surgical options 3
• Parathyroidectomy should likely not be too radical, especially if the patient is a candidate for future renal transplantation 3
• Ideally, parathyroidectomy should be performed before kidney transplantation to prevent persistent hyperparathyroidism and improve graft outcomes 4

Healthcare Professionals Involved

The management of hyperparathyroidism related to renal failure involves a team of healthcare professionals, including:

• Nephrologists to manage renal failure and hyperparathyroidism 4, 7
• Endocrine surgeons to perform parathyroidectomy 3, 4, 7
• Radiologists to evaluate parathyroid gland size and guide surgical decisions 4