Management of secondary hyperparathyroidism and mineral metabolism abnormalities in adult predialysis patients with chronic kidney disease
- L Darryl Quarles, MD
L Darryl Quarles, MD
- Section Editor — Renal Osteodystrophy
- Director, Division of Nephrology
- Associate Dean for Research
- The University of Tennessee Health Science Center
- Michael Berkoben, MD
Michael Berkoben, MD
- Associate Professor of Medicine
- Duke University Medical Center
The treatment of secondary hyperparathyroidism in chronic kidney disease (CKD) is based upon our understanding of the pathogenesis and clinical features of this disorder and the recognition that abnormal calcium and phosphate homeostasis may increase morbidity and mortality.
Because of the interdependence of calcium, phosphate, vitamin D, and parathyroid hormone (PTH), it is difficult to elucidate the individual contributions of each of the various causes of parathyroid gland dysfunction in patients with CKD. In addition, no single pharmacologic intervention is sufficient to completely restore disordered calcium and phosphate homeostasis in the setting of advancing deterioration of renal function.
The following topic review addresses issues related to the treatment of secondary hyperparathyroidism and mineral metabolism abnormalities (also referred to as chronic kidney disease-mineral bone disorder [CKD-MBD]) in patients with stage 3 to 5 CKD not yet on dialysis. Among patients with CKD but normal or near-normal kidney function (stage 1 to 2 CKD), issues related to bone disease and abnormalities in calcium and phosphorus levels are discussed separately. The treatment of secondary hyperparathyroidism in adult dialysis patients is also presented separately. (See "Overview of the management of osteoporosis in postmenopausal women" and "Management of secondary hyperparathyroidism and mineral metabolism abnormalities in dialysis patients".)
The pathogenesis of secondary hyperparathyroidism is also discussed separately. (See "Overview of chronic kidney disease-mineral bone disease (CKD-MBD)", section on 'Overview'.)
PATHOGENESIS OF SECONDARY HYPERPARATHYROIDISM
To understand the management of secondary hyperparathyroidism and mineral metabolism abnormalities in patients with CKD, it is important to understand the pathogenesis and clinical features of these disorders. This is discussed separately. (See "Overview of chronic kidney disease-mineral bone disease (CKD-MBD)", section on 'Overview' and "Management of secondary hyperparathyroidism and mineral metabolism abnormalities in dialysis patients", section on 'Clinical features'.)
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- PATHOGENESIS OF SECONDARY HYPERPARATHYROIDISM
- OVERVIEW OF THERAPY
- Step 1
- Step 2
- Step 3
- Step 4
- GOAL TARGET LEVELS
- K/DOQI target levels
- - Parathyroid hormone levels
- - Calcium and phosphate levels
- KDIGO guidelines
- - Laboratory values
- ASSESSMENT AND MONITORING
- TREATMENT OPTIONS
- Dietary phosphate restriction and phosphate binders
- - Dietary restriction
- - Phosphate binders
- Vitamin D, calcitriol, and vitamin D analogs
- Vitamin D deficiency
- Calcitriol and synthetic vitamin D analogs
- SUMMARY AND RECOMMENDATIONS