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 involves:
- 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) to reduce phosphate absorption
- 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, calcimimetics such as cinacalcet (starting at 30 mg daily, titrated up to 180 mg if needed) can be added to directly reduce PTH production. In severe cases unresponsive to medical therapy, parathyroidectomy may be necessary, as indicated by studies such as 1. Regular monitoring of calcium, phosphate, and PTH levels is essential, as is addressing underlying kidney disease through appropriate renal replacement therapy, as recommended by guidelines such as those outlined in 1, 1, 1, 1, 1, 1, and 1. This comprehensive approach is needed because kidney failure disrupts mineral metabolism, leading to phosphate retention and decreased vitamin D activation, which stimulates parathyroid gland hyperplasia and excessive PTH secretion. 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 in patients receiving dialysis, as recommended by guidelines such as those outlined in 1 and 1. Overall, the management of hyperparathyroidism in renal failure requires a multidisciplinary approach, with careful attention to mineral metabolism, bone health, and cardiovascular risk factors.
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
- Endocrinologists
- 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 vitamin D receptor activators, such as paricalcitol, and calcimimetics, such as cinacalcet 4
Surgical Treatment
Surgical treatment, parathyroidectomy, is considered when medical therapy cannot control the hyperparathyroidism 3, 5, 6
- 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 5
Treatment Outcomes
Treatment outcomes for hyperparathyroidism related to renal failure include: