From the Guidelines

The best management for a patient with hypercalcemia and hyperphosphatemia is to avoid hypercalcemia and treat hyperphosphatemia.

In adult patients with CKD G3a to G5D, avoiding hypercalcemia is suggested [ 1 ].
Treatment should be focused on patients with hyperphosphatemia, rather than maintaining normal phosphate levels [ 1 ].
Calcimimetics, such as cinacalcet, may be used to lower PTH levels in patients with CKD G5D [ 1 ].
Surgical parathyroidectomy may be indicated in cases of severe hyperparathyroidism associated with hypercalcemia and/or hyperphosphatemia [ 1 ].

Use a dialysate calcium concentration between 1.25 and 1.50 mmol/L (2.5 and 3.0 mEq/L) in patients with CKD G5D [ 1 ].
Phosphate binders may be used to treat hyperphosphatemia, but their efficacy and safety have been questioned in certain populations [ 1 ].
Vitamin D analogues may be used to treat secondary hyperparathyroidism, but their use should be reserved for severe and progressive cases [ 1 ].

From the Research

The management of hypercalcemia and hyperphosphatemia involves a combination of treatments aimed at reducing serum calcium and phosphorus levels.

For hyperphosphatemia, phosphate binders such as calcium acetate, sevelamer, and lanthanum are effective in reducing serum phosphorus levels 2, 3.
However, calcium-based binders can lead to hypercalcemia, and therefore, should be used with caution in patients with hypercalcemia 2, 3.
In patients with hypercalcemia, treatment options include fluid repletion, intravenous bisphosphonates, and calcitonin 4, 5.
Bisphosphonates are effective in reducing serum calcium levels, but can cause renal toxicity and hypocalcemia 5.
The choice of treatment depends on the underlying cause of hypercalcemia and hyperphosphatemia, as well as the severity of the condition 4, 5.

Phosphate binders are the mainstay of treatment for hyperphosphatemia, and include:
- Calcium acetate: effective in reducing serum phosphorus levels, but can lead to hypercalcemia 3.
- Sevelamer: effective in reducing serum phosphorus levels, but can cause gastrointestinal side effects 2, 3.
- Lanthanum: effective in reducing serum phosphorus levels, with minimal risk of hypercalcemia 2.
Other treatment options for hyperphosphatemia include dietary phosphate restriction and vitamin D supplementation 6.

Treatment options for hypercalcemia include:
- Fluid repletion: aims to restore normal fluid balance and reduce serum calcium levels 5.
- Intravenous bisphosphonates: effective in reducing serum calcium levels, but can cause renal toxicity and hypocalcemia 5.
- Calcitonin: effective in rapidly reducing serum calcium levels, but has limited efficacy in normalizing serum calcium levels 5.
- Gallium nitrate: may be effective in reducing serum calcium levels, but has limited data and potential renal toxicity 5.