KDIGO Guidelines for PTH Management in CKD
PTH Target Ranges by CKD Stage
For patients with CKD G5D (on dialysis), maintain intact PTH levels at approximately 2 to 9 times the upper normal limit of the assay. 1, 2
CKD G5D (Dialysis Patients)
- The target range is 2-9 times the upper limit of normal (ULN) for your specific PTH assay 1, 2
- This represents a shift from rigid numerical targets to assay-specific ranges 1
- Treatment decisions should be based on trends rather than single measurements 2
- If PTH falls below 2 times ULN, reduce or stop calcitriol, vitamin D analogs, and/or calcimimetics 1
CKD G3a-G5 (Not on Dialysis)
- No specific PTH target range is established for patients not on dialysis 1, 2
- Progressively rising or persistently elevated PTH above ULN warrants investigation for modifiable factors 2, 3
- Evaluate and correct: hyperphosphatemia, hypocalcemia, high phosphate intake, and vitamin D deficiency 2, 4
- High and progressively increasing PTH levels are independently associated with CKD progression, cardiovascular events, mortality, and fractures 1
Treatment Approach
First-Line PTH-Lowering Options for G5D
No single PTH-lowering treatment is prioritized; calcimimetics, calcitriol, or vitamin D analogs are all acceptable first-line options. 1
- Calcimimetics (cinacalcet, etelcalcetide, evocalcet, upacicalcet) effectively reduce PTH 1
- Calcitriol or vitamin D analogs are equally acceptable 1
- Choice depends on concurrent biochemical abnormalities (calcium, phosphate levels) 2
When to Reduce or Stop Treatment
Hypercalcemia:
- Reduce or stop calcitriol or vitamin D sterols (Grade 1B recommendation) 1
Hyperphosphatemia:
- Reduce or stop calcitriol or vitamin D sterols (Grade 2D recommendation) 1
Hypocalcemia:
- Reduce or stop calcimimetics depending on severity, concomitant medications, and clinical symptoms (Grade 2D recommendation) 1
Low PTH:
- If intact PTH falls below 2 times ULN, reduce or stop all PTH-lowering agents (Grade 2C recommendation) 1
Special Considerations for CKD G3a-G5 Not on Dialysis
Avoid routine use of calcitriol or activated vitamin D in patients with CKD not on dialysis. 1, 4
- The PRIMO and OPERA trials showed activated vitamin D increased hypercalcemia risk without cardiac benefits 1
- Reserve active vitamin D for severe and progressive hyperparathyroidism only 4
- Low-dose active vitamin D may be helpful as supplement to nutritional vitamin D and dietary phosphate restriction for PTH control 1
- Extended-release calcifediol can suppress PTH by raising 25-(OH)D to >125 nmol/L, but clinically relevant outcome data are lacking 1
Monitoring Strategy
Base monitoring frequency on baseline PTH level and rate of CKD progression. 2
- Increase monitoring frequency if PTH is rising or persistently elevated 2
- Monitor calcium and phosphate at least every 3 months after initiating vitamin D therapy 4
- Assess trends in PTH levels together with calcium and phosphate—not PTH in isolation 2
Surgical Management
Consider parathyroidectomy for severe hyperparathyroidism failing medical therapy. 2
- Parathyroidectomy obviates multiple drug titrations and shows more substantial BMD increases 1
- Japanese registry data suggest parathyroidectomy associated with lower mortality than calcimimetics 1
- For post-transplant persistent hyperparathyroidism, subtotal parathyroidectomy induces greater PTH/calcium reductions and increases femoral neck BMD compared to cinacalcet 1
- Recent meta-analysis shows no long-term negative impact on allograft function 1
Critical Pitfalls to Avoid
Do not chase "normal" PTH levels in CKD patients. 1, 5
- Modest PTH elevation likely represents appropriate adaptive response to declining kidney function 5
- U- or J-shaped curves exist between PTH and all-cause mortality in epidemiologic studies 1
- Bone turnover can be low even with normal-range PTH, or high with only moderately elevated PTH 1