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 reduction. 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 for patients with persistently elevated PTH levels
- Parathyroidectomy for severe cases unresponsive to medical therapy Regular monitoring of calcium, phosphate, and PTH levels is essential to guide treatment adjustments, as noted in the 2017 clinical practice guideline update 1. Key considerations in treatment include avoiding inappropriate calcium loading, restricting the use of calcium-based phosphate binders in patients with hyperphosphatemia, and reserving the use of calcitriol and vitamin D analogues for patients with severe and progressive hyperparathyroidism 1. The goal of treatment is to manage 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.
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 treat hyperparathyroidism related to renal failure, as they specialize in the care of patients with kidney disease.
- They often work in collaboration with endocrinologists, who specialize in the treatment of hormone-related disorders, including hyperparathyroidism.
- Primary care physicians may also be involved in the initial diagnosis and referral of patients to specialists. 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: