2. Switch to non-calcium containing binders (including rescue aluminum)
3. Dietary phosphate intake and adherence to dose and timing of binder ingestion should be reviewed.
PTH Management
If vitamin D sterol therapy is being used in this patient, the dose should be decreased to reduce the hypercalcemia, and, to a lesser extent, the hyperphosphatemia. This may result in a further increase in PTH levels. It would not be wise to initiate vitamin D sterol therapy while the phosphate and calcium were both high.
This patient has hyperparathyroidism despite hypercalcemia. This suggests that the parathyroid glands are poorly responsive or unresponsive to calcium levels. The hyperparathyroidism may prove difficult to control medically. The use of a calcimimetic agent such may result in a fall in PTH, calcium and phosphate in this patient, but the hyperparathyroidism may be such that it is autonomous and poorly responsive to calcimimetics. Consideration should be given to parathyroidectomy in this case.
Other Controversies in Management
Aluminum use:
The K/DOQI guidelines allow for the use of “rescue aluminum”:
GUIDELINE 5. USE OF PHOSPHATE BINDERS IN CKD
Chapter 5.8 In patients with serum phosphorus levels >7.0 mg/dL (2.26 mmol/L), aluminum-based phosphate binders may be used as a short-term therapy (4 weeks), and for one course only, to be replaced thereafter by other phosphate binders. (OPINION)
This opinion based guideline is not accepted by all, and many authors recommend complete avoidance of aluminum. The following position was adopted by the KDIGO group:
Chapter 4.1: Treatment of CKD–MBD targeted at lowering high serum phosphorus and maintaining serum calcium
4.1.6 In patients with CKD stages 3–5D, we recommend avoiding the long-term use of aluminum-containing phosphate binders.
Duration of Dialysis
Excellent control of phosphate has been achieved during long (8 hour) sessions of hemodialysis. Short daily dialysis has not achieved the same degree of phosphate control.
(Semin Dial. 2007 Jul-Aug;20(4):342-5. Phosphorus balance with daily dialysis. Kooienga L)
Parathyroidectomy
While registry data (USRDS) have suggested a survival benefit to parathyroidectomy in CKD5D patients, the timing and indications for parathyroidectomy are not clear.
The K/DOQI guidelines suggest the following:
GUIDELINE 14. PARATHYROIDECTOMY IN PATIENTS WITH CKD Parathyroidectomy should be recommended in patients with severe hyperparathyroidism (persistent serum levels of intact PTH >800 pg/mL [88.0 pmol/L]), associated with hypercalcemia and/or hyperphosphatemia that are refractory to medical therapy. (OPINION)
The following position was adopted by the KDIGO group:
Chapter 4.2: Treatment of abnormal PTH levels in CKD–MBD
4.2.5 In patients with CKD stages 3–5D with severe hyperparathyroidism (HPT) who fail to respond to medical/pharmacological therapy, we suggest parathyroidectomy.
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