How to correct elevated intact parathyroid hormone (iPTH) levels in chronic kidney disease (CKD)?

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Dainyal Siddiqui, MD

Internal Medicine

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Manuel Jimenez, MD

Cardiology

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Franz Pierre-Louis, MD

Infectious Disease

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Last updated: February 24, 2025 • View editorial policy

From the Guidelines

To correct elevated iPTH levels in chronic kidney disease, treatment should focus on patients with progressively increasing or persistently elevated PTH levels, and not on a single elevated value, as recommended by the Kidney Disease: Improving Global Outcomes 2017 clinical practice guideline update 1.

Treatment Approach

The treatment approach for secondary hyperparathyroidism (SHPT) in patients with CKD should be based on serial assessments of biochemical variables, including serum phosphate, calcium, and PTH levels.

  • In patients with CKD G3a to G5 not on dialysis, calcitriol and vitamin D analogues should not be routinely used due to the increased risk of hypercalcemia, as suggested by the 2017 guideline update 2.
  • In patients with CKD G5D requiring PTH-lowering therapy, calcimimetics, calcitriol, or vitamin D analogues, or a combination of calcimimetics with calcitriol or vitamin D analogues may be considered, as recommended by the guideline update 3.

Dietary Changes

  • Restrict dietary phosphorus intake to 800-1000 mg/day to control serum phosphorus levels, which is crucial as hyperphosphatemia stimulates PTH production.
  • Use phosphate binders with meals, such as calcium acetate or sevelamer, to control phosphate levels.

Monitoring

  • Monitor calcium, phosphorus, and iPTH levels regularly and adjust treatment as needed to balance these treatments and avoid complications like hypercalcemia or adynamic bone disease. The interventions work together to address the underlying causes of SHPT in CKD, and regular monitoring is essential to balance these treatments and avoid complications 4.

From the FDA Drug Label

To correct elevated intact parathyroid hormone (iPTH) levels in chronic kidney disease (CKD), the dose of paricalcitol capsules should be individualized and titrated based on iPTH, serum calcium, and phosphorus levels.

For CKD Stages 3 and 4 in adults, the initial dose is based on the baseline iPTH level, with a daily dose of 1 mcg for iPTH less than or equal to 500 pg/mL and 2 mcg for iPTH more than 500 pg/mL. The dose can be increased by 1 mcg every 2 to 4 weeks if iPTH levels remain elevated.

For CKD Stage 5 in adults, the initial dose is calculated based on the baseline iPTH level, with a dose of paricalcitol capsules orally three times a week, no more frequently than every other day, using the formula: Dose (micrograms) = baseline iPTH (pg/mL) divided by 80.

Dose titration should be based on the following formula: Dose (micrograms) = most recent iPTH level (pg/mL) divided by 80. If serum calcium is elevated, the dose should be decreased by 2 to 4 micrograms.

The recommended approach to correct elevated iPTH levels in CKD is to:

  • Individualize the dose of paricalcitol capsules based on iPTH, serum calcium, and phosphorus levels.
  • Titrate the dose every 2 to 4 weeks, using the formulas provided in the drug label.
  • Monitor serum calcium and phosphorus levels closely after initiation of paricalcitol capsules and during dose titration periods.
  • Adjust the dose as needed to maintain an iPTH level within the target range, while minimizing the risk of hypercalcemia [5] [6].

From the Research

Correction of Elevated Intact Parathyroid Hormone (iPTH) Levels

To correct elevated intact parathyroid hormone (iPTH) levels in chronic kidney disease (CKD), several approaches can be considered:

  • Cinacalcet therapy: Cinacalcet is usually used for CKD-mineral and bone disorders (CKD-MBD) patients with elevated iPTH levels. However, a study found that early initiation of cinacalcet therapy can be effective in controlling hypercalcemia, hyperphosphatemia, and increased iPTH in CKD-MBD patients, even in those without marked elevation of iPTH 7.
  • Vitamin D supplementation: Vitamin D supplements may be a valuable tool in the prevention and treatment of hyperparathyroidism in patients with stages 3 and 4 CKD. A study found that patients who took 400 IU of vitamin D daily with supplemental calcium had higher 25(OH)D and 1,25(OH)D levels, lower iPTH levels, and were more likely to meet K-DOQI PTH guidelines 8.
  • Monitoring of iPTH levels: Emphasis should be given to monitoring iPTH levels in early stages of CKD, as majority of patients are out of target range of iPTH even with normal serum calcium and phosphate levels 9.
  • Assessment of biochemistry markers: Biochemistry markers such as creatinine, estimated glomerular filtration rate (eGFR), vitamin D, calcium, and inorganic phosphate can be used to monitor CKD-MBD and prevent its complications 10.

Treatment Options

Treatment options for elevated iPTH levels in CKD include:

  • Phosphate binders: Phosphate binders can help control hyperphosphatemia, which is often associated with elevated iPTH levels.
  • Vitamin D sterols: Vitamin D sterols can help regulate calcium and phosphate metabolism and reduce iPTH levels.
  • Cinacalcet: Cinacalcet can help reduce iPTH levels and control hypercalcemia and hyperphosphatemia.

Important Considerations

Important considerations when correcting elevated iPTH levels in CKD include:

  • Regular monitoring: Regular monitoring of iPTH levels, serum calcium, and phosphate levels is crucial to adjust treatment and prevent complications.
  • Individualized treatment: Treatment should be individualized based on the patient's specific needs and stage of CKD.
  • Multidisciplinary approach: A multidisciplinary approach involving nephrologists, dietitians, and other healthcare professionals is essential to manage CKD-MBD and prevent its complications 9, 10, 11, 8.

References

7
Research

Chronic hemodialysis patients without marked elevation of intact parathyroid hormone are also good candidates for early intervention with cinacalcet.

Therapeutic apheresis and dialysis : official peer-reviewed journal of the International Society for Apheresis, the Japanese Society for Apheresis, the Japanese Society for Dialysis Therapy, 2013

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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