Dialysis Prescription
Reduction in the dialysate calcium by 0.25-0.50 mmol/L (0.50 – 1.0 mEq/L) may alleviate the hypercalcemia, but will also exacerbate the secondary hyperparathyroidism
Phosphate and Calcium Management
Therapeutic avenues;
PTH Management
Vitamin D Sterols
If vitamin D sterols are in use, the PTH is high despite them and hypercalcemia is present. Therapeutic avenues;
Calcimimetics
This is the therapy of choice in this situation, with the potential to correct the hyperparathyroidism and normalize serum calcium.
Neither the CSN, nor the KDIGO guidelines comment on the specific role of calcimimetics in this situation. No specific evidence relates to the role of this agent in preventing a need for parathyoidectomy.
Block et al published the Phase III randomised controlled trial of cinecalcet in patients with severe secondary hyperparathyroidsm. (Cinacalcet for Secondary Hyperparathyroidism in Patients Receiving Hemodialysis, New Engl.J.Med 350:1516,2004)
Other Options or Controversies in Management
Parathyroidectomy
Hypercalcemic patients with very high serum (intact)PTH levels (e.g. > 60 pmol/L) often fail medical therapy (outlined above), and require parathyroidectomy
Suggested Guidelines;
CSN
8. Parathyroidectomy should be considered for those patients who have failed standard treatments and have persistently elevated PTH levels with systemic complications. (Grade D, opinion)
KDIGO
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 (2B).
Elder has reviewed this topic (Elder GJ, Parathyroidectomy in the calcimimetic era, Nephrology 2005). Parathyroidectomy may be the treatment of choice when averaged serum intact-PTH levels are consistently above 85-95 pmol/L despite optimal therapy.
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