From the Guidelines
For patients with secondary hyperparathyroidism due to chronic kidney disease, total parathyroidectomy (TPTX) is the recommended surgical approach, as it has been shown to reduce the incidence of various complications of CKD, such as stroke and cardiovascular and all-cause mortality, compared to subtotal parathyroidectomy (SPTX) and total parathyroidectomy with autotransplantation (TPTX + AT) 1.
Treatment Overview
Secondary hyperparathyroidism is a common complication of chronic kidney disease (CKD), resulting from the malregulation of calcium and phosphate, leading to increased secretion of parathyroid hormone (PTH) 1. The clinical manifestations include high levels of PTH, hyper- or hypocalcemia, and persistently high phosphorus levels, leading to diseases of the skeletal, nervous, and cardiovascular systems.
Medical Management
Before considering surgical intervention, medical management is crucial, including:
- A lower-phosphorus diet
- Dialysis treatment
- Drug supplementation, such as:
- Phosphorus binding agents
- Calcium receptor agonists
- Vitamin D and its analogues
Surgical Intervention
For patients with refractory or progressive secondary hyperparathyroidism, surgical intervention may be necessary. The choice of surgical approach is crucial, with options including subtotal parathyroidectomy (SPTX), total parathyroidectomy (TPTX), and total parathyroidectomy with autotransplantation (TPTX + AT) 1.
Recommended Surgical Approach
Total parathyroidectomy (TPTX) is the preferred surgical approach, as it has been shown to reduce the incidence of various complications of CKD, such as stroke and cardiovascular and all-cause mortality, compared to SPTX and TPTX + AT 1. Recent studies suggest that the hypocalcemia induced by TPTX is mostly temporary and occurs without the appearance of persistent hypocalcemia or adynamic bone diseases 1. Additionally, TPTX has great advantages over SPTX and TPTX + AT in reducing the relapse of secondary hyperparathyroidism.
Post-Surgical Management
After surgical intervention, regular monitoring of calcium, phosphate, PTH, and vitamin D levels is essential to guide therapy and prevent complications like bone disease and cardiovascular calcifications. Early intervention is crucial, as prolonged secondary hyperparathyroidism can lead to autonomous parathyroid function (tertiary hyperparathyroidism) 1.
From the FDA Drug Label
Cinacalcet tablets are indicated for the treatment of secondary hyperparathyroidism (HPT) in adult patients with chronic kidney disease (CKD) on dialysis [see Clinical Studies (14. 1)]. The recommended starting oral dose of cinacalcet tablets is 30 mg once daily. 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.
Secondary Hyperparathyroidism is a condition that can be treated with cinacalcet tablets in adult patients with chronic kidney disease (CKD) on dialysis. The treatment should be initiated with a dose of 30 mg once daily and titrated every 2 to 4 weeks to achieve iPTH levels of 150 to 300 pg/mL 2.
From the Research
Definition and Pathophysiology of Secondary Hyperparathyroidism
- Secondary hyperparathyroidism (SHPT) is a complication of chronic kidney disease (CKD) characterized by an overproduction of parathyroid hormone (PTH) 3, 4, 5, 6, 7.
- The condition arises due to alterations in the vitamin D system, including reduced levels of 25-hydroxy-vitamin D (25[OH]D) and 1,25-dihydroxyvitamin D (1,25[OH]2D), leading to hypocalcemia and hyperphosphatemia 5, 6.
- The defect in vitamin D activation in the kidneys due to CKD results in a compensatory increase in parathyroid gland cellularity and PTH production, causing SHPT 6.
Clinical Presentation and Complications
- SHPT is associated with important clinical outcomes, such as kidney disease progression, fractures, cardiovascular events, and mortality 4.
- The condition can lead to skeletal and cardiovascular disease, as well as other extra-skeletal complications 5.
- Untreated SHPT may degenerate into tertiary hyperparathyroidism with detrimental consequences in advanced CKD 3.
Management and Treatment
- The best treatment for low 25(OH)D and SHPT remains unknown due to incomplete understanding of the best homeostatic adaptation of mineral metabolism to CKD progression 3.
- Nutritional vitamin D and nutritional therapy appear to be the safest interventions, contextualized with single-patient characteristics 3.
- Vitamin D receptor activators (VDRA) should be restricted to uncontrolled SHPT by first-line therapy 3.
- Medical interventions, such as vitamin D analogs, calcium receptor blockers, and parathyroidectomy, may be necessary in some CKD patients to control serum calcium, phosphate, and PTH 6.
- Maintaining acceptable levels of mineral metabolism parameters is crucial in the management of CKD to slow down or prevent the development of SHPT 7.