From the Guidelines
Hyperparathyroidism related to renal failure is typically treated by a nephrologist or an endocrinologist with a multi-faceted approach targeting phosphate control, vitamin D supplementation, and PTH regulation. The treatment approach involves:
- Dietary phosphate restriction
- Phosphate binders such as calcium acetate, sevelamer, or lanthanum carbonate to reduce phosphate absorption
- Active vitamin D analogs like calcitriol or paricalcitol to suppress PTH secretion
- Calcimimetics such as cinacalcet to increase calcium-sensing receptor sensitivity in the parathyroid glands
- Regular monitoring of calcium, phosphate, and PTH levels to guide treatment adjustments, as recommended by the Kidney Disease: Improving Global Outcomes (KDIGO) 2017 clinical practice guideline update 1. In severe cases unresponsive to medical therapy, parathyroidectomy may be necessary, as suggested by studies on the treatment of secondary hyperparathyroidism in patients with chronic kidney disease 1. The goal of treatment is to address the underlying pathophysiology of hyperparathyroidism in renal failure, which involves phosphate retention, decreased vitamin D activation, and subsequent parathyroid gland hyperplasia and excessive PTH production. Key considerations in treatment include:
- Avoiding inappropriate calcium loading in adults with CKD, as hypercalcemia may be harmful in all GFR categories of CKD 1
- Restricting the use of calcium-based phosphate binders in patients with hyperphosphatemia across the CKD spectrum 1
- Reserving the use of calcitriol and vitamin D analogues for patients with CKD G4 to G5 with severe and progressive hyperparathyroidism 1.
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.
Treatment of hyperparathyroidism related to renal failure is typically managed by a nephrologist or a primary care physician in collaboration with a nephrologist, using medications such as cinacalcet. The treatment involves:
- Monitoring serum calcium and phosphorus levels
- Adjusting the dose of cinacalcet to target iPTH levels of 150 to 300 pg/mL
- Using calcium-containing phosphate binders and/or vitamin D sterols to raise serum calcium if necessary 2
From the Research
Treatment of Hyperparathyroidism Related to Renal Failure
Hyperparathyroidism related to renal failure is typically treated by a multidisciplinary team of experienced nephrologists, transplant, and endocrine surgeons 3. The treatment consists of:
- Medical therapy, which includes supplying vitamin D and reducing phosphate intake 4
- Calcimimetics, which decrease serum levels of parathyroid hormone (PTH) and calcium, and are a potential alternative for patients contraindicated for parathyroidectomy (PTX) or who have failed previous PTX and have recurrent primary HPT 5, 6
- Surgical parathyroidectomy, which is an option when medical therapy cannot control the hyperparathyroidism 4, 3
Medical Treatment
The medical treatment of hyperparathyroidism related to renal failure includes:
- Vitamin D receptor activators (VDRAs), which are widely used for treatment of secondary hyperparathyroidism (SHPT) 7
- Calcimimetics, which have been developed as alternative drugs for SHPT and have been shown to reduce PTH, calcium, phosphate, and calcium x phosphate product in end-stage renal disease (ESRD) patients 5, 6
- Control of hyperphosphatemia, which is thought to be fundamental for control of SHPT 7
Surgical Treatment
Surgical parathyroidectomy is indicated only when conservative treatment options fail 3. The surgical options include: