What is the target parathyroid hormone (PTH) range for patients with Chronic Kidney Disease (CKD)?

Target PTH Range for CKD Stages

For patients with CKD G5D (on dialysis), intact PTH levels should be maintained in the range of approximately 2 to 9 times the upper normal limit for the assay. 1

PTH Targets by CKD Stage

Non-Dialysis CKD (G3a-G5)

• For patients with CKD G3a-G5 not on dialysis, the optimal PTH level is not definitively established 1
• Patients with progressively rising or persistently elevated PTH above the upper normal limit should be evaluated for modifiable factors including: 1
  • Hyperphosphatemia
  • Hypocalcemia
  • High phosphate intake
  • Vitamin D deficiency

Dialysis-Dependent CKD (G5D)

• Target intact PTH range: approximately 2-9 times the upper normal limit of the assay 1
• Marked changes in PTH levels in either direction within this range should prompt initiation or change in therapy 1
• This wider target range (compared to earlier guidelines) helps avoid adynamic bone disease that can occur when PTH is suppressed too aggressively 2

Monitoring Frequency

CKD G3a-G5 (Non-Dialysis)

• Monitoring frequency should be based on baseline PTH level and CKD progression 1
• More frequent monitoring is recommended if PTH is rising or persistently elevated 1

CKD G5D (Dialysis)

• Monthly PTH monitoring may be more effective than quarterly monitoring in achieving target ranges 3
• Regular monitoring allows for appropriate titration of medications to maintain PTH within target range 4

Therapeutic Considerations

• Treatment decisions should be based on trends in PTH levels rather than single measurements 1, 5
• When PTH levels are outside the target range: 1
  • For elevated PTH: Consider calcimimetics, calcitriol, or vitamin D analogs, or combinations 1
  • For low PTH: Consider reducing or discontinuing medications that suppress PTH 6

Important Caveats

• PTH assay variability is significant; the same sample measured with different assays can yield different results 2
• Second-generation "intact PTH" assays measure both full-length biologically active PTH and inactive fragments that accumulate in CKD 2
• A modest increase in PTH may represent an appropriate adaptive response to declining kidney function due to phosphaturic effects and increasing bone resistance 5
• Parathyroidectomy should be considered in patients with severe hyperparathyroidism who fail to respond to medical therapy 1

Integrated Approach

• Treatment of CKD-MBD should be based on serial assessments of phosphate, calcium, and PTH levels considered together, not just PTH in isolation 1
• Avoid hypercalcemia in adults with CKD G3a-G5D 1
• Maintain serum phosphorus toward the normal range 1
• Consider the presence of vascular or valvular calcification in risk assessment and management 1