According to KDIGO, what are the target intact parathyroid hormone levels for each chronic kidney disease stage based on estimated glomerular filtration rate?

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KDIGO PTH Target Levels by CKD Stage Based on GFR

KDIGO does not provide specific numeric PTH targets for CKD stages 3-5 non-dialysis patients; instead, clinicians should monitor PTH trends when eGFR falls below 60 mL/min/1.73 m² and only apply the defined target range of 2-9 times the upper limit of normal (approximately 130-585 pg/mL) to dialysis patients (CKD stage 5D). 1

Monitoring Initiation and Frequency

Begin measuring intact PTH (iPTH) when eGFR drops below 60 mL/min/1.73 m², which corresponds to the transition from CKD stage 2 to stage 3. 1 KDIGO recommends measuring serum calcium, phosphate, PTH, and alkaline phosphatase at least once in adults with eGFR <45 mL/min/1.73 m² (stages G3b-G5) to establish baseline values. 2

  • CKD Stage 3a (eGFR 45-59): Monitor PTH at least annually 2
  • CKD Stage 3b (eGFR 30-44): Increase monitoring frequency as kidney function declines 1
  • CKD Stage 4 (eGFR 15-29): Continue regular iPTH monitoring with increased frequency 1
  • CKD Stage 5 non-dialysis (eGFR <15): Monitor closely, particularly if on PTH-lowering therapy 1
  • CKD Stage 5D (dialysis): Apply specific target range (see below) 1

PTH Target Ranges by CKD Stage

CKD Stages 3-5 (Non-Dialysis)

No specific numeric PTH target exists for non-dialysis CKD patients. 1 KDIGO recommends that patients with iPTH levels above the upper normal limit should first be evaluated for hyperphosphatemia, hypocalcemia, and vitamin D deficiency before initiating PTH-lowering therapy. 2

The key management principle is trend monitoring rather than targeting absolute values. 1 Track PTH changes over time and correlate with concurrent calcium and phosphorus abnormalities to guide therapeutic decisions. 1

Critical lower threshold: When iPTH falls below 2 times the upper limit of normal (approximately <130 pg/mL) in CKD stage 5 non-dialysis patients receiving PTH-lowering agents, avoid further suppression to reduce risk of adynamic bone disease. 1

CKD Stage 5D (Dialysis Only)

The only population with a defined PTH target range is dialysis patients: maintain iPTH between 2-9 times the upper limit of normal (approximately 130-585 pg/mL for assays with ULN ≈65 pg/mL). 1

This target is based on bone biopsy studies demonstrating that this range best predicts appropriate bone turnover in dialysis patients. 1

Treatment Thresholds and Interventions

When PTH is Too Low

If iPTH falls below 2 times ULN in dialysis patients, reduce or discontinue calcitriol, vitamin D analogs, and/or calcimimetics (Grade 2C recommendation). 1 This same lower threshold applies to CKD stage 5 non-dialysis patients on PTH-lowering therapy. 1

When PTH is Elevated

For non-dialysis CKD patients with elevated PTH above the upper normal limit, systematically evaluate and correct the following before initiating PTH-lowering therapy: 2

  1. Hyperphosphatemia: Maintain serum phosphate in the normal range according to local laboratory reference values 2
  2. Hypocalcemia: Correct calcium deficiency 2
  3. Vitamin D deficiency: Address documented deficiency 2

Do not routinely prescribe vitamin D supplements or analogs solely to suppress elevated PTH in non-dialysis CKD patients without documented deficiency (Grade 2B). 2

Critical Pitfalls to Avoid

  • Never apply the dialysis 2-9 times ULN target to non-dialysis CKD patients—KDIGO explicitly limits this range to stage 5D only 1
  • Do not diagnose or treat based on a single iPTH measurement in stages 3-5 non-dialysis—trends are emphasized over isolated values 1
  • Recognize assay variability: Intact PTH assays may include inactive fragments that accumulate as GFR declines, potentially inflating measured values 1
  • Avoid over-suppression: PTH levels below 2 times ULN increase risk of adynamic bone disease 1

Rationale for Guideline Evolution

The 2017 KDIGO update removed specific iPTH targets for non-dialysis CKD stages because robust evidence linking particular PTH levels to patient-centered outcomes (mortality, fractures, cardiovascular events) is lacking in CKD stages 3-5. 1 The dialysis population retained the 2-9 times ULN target because bone biopsy data support this range for predicting appropriate bone turnover. 1

References

1
Guideline

KDIGO Guidelines for Intact PTH Management Across CKD Stages

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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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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