Secondary Hyperparathyroidism: Pathophysiology and Treatment

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Figure 1.
Normal calcium and phosphorus homeostasis. PTH, parathyroid hormone; FGF-23, fibroblasts growth factor 23.
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Figure 2.
Calcium and phosphorus metabolism in renal failure. PTH, parathyroid hormone; FGF-23, fibroblasts growth factor 23.

Table 1.

Stages of Chronic Kidney Disease

Stage	Description	GFR (mL/min/1.73m²)
I	Kidney damage with normal/increased GFR	≥90
II	Kidney damage with mild decrease in GFR	60–89
III	Moderate decrease in GFR	30–59
IV	Severe decrease in GFR	15–29
V	Kidney failure	<15

Table 2.

Frequency of Measurement and Target Ranges of Parathyroid Hormone (PTH) and Phosphorus According to Stage of Chronic Kidney Disease

Stage	GFR Range (mL/min/1.73m²)	Measurement of PTH	Measurement of Calcium and Phosphorus	Target PO₄ (mg/dL)	Target PTH (pg/mL)
III	30 to 59	Every 12 months	Every 12 months	2.7 to 4.6	30 to 70 (level B)
IV	15 to 29	Every 3 months	Every 3 months	2.7 to 4.6	70 to 110 (level B)
V	<15 or dialysis	Every 3 months	Every month	3.5 to 5.5	150 to 300 (level A)

Table 3.

Stepped Approach for Management of Secondary Hyperparathyroidism

Step	Drugs Used	Goals
I	· Low-phosphorus diet · Phosphate binders · Ergocalciferol (stages III and IV)	· Calcium and phosphorus within normal ranges (depending on stage of CKD) · 25-hydroxyvitamin D >30 pg/mL
II	· Cinacalcet · Vitamin D sterols (calcitriol, paricalcitol, and doxecalciferol)	· PTH within normal ranges (depending on stage of CKD)
III	· Adjust doses	· Calcium, phosphorus, and PTH within K/DOQI recommendations

CKD, chronic kidney disease; PTH, parathyroid hormone; K/DOQI, Kidney Disease Outcomes Quality Initiative.

Table 4.

Phosphorus Content of Common Foods that Contain Protein

Food	Soybeans (roasted)	Cream Cheese	Roast Beef Sandwich	Pork	Chicken Breast	Shrimp	Peanut Butter	Lemonade
Measurement	1 cup	2 tb	1 sandwich	3 oz	3 oz	3 oz	2 tb	1 cup
Protein (g)	61	2	21.5	22	27	18	8	0.3
Phosphorus (mg)	624	30	239	146	196	116	101	5
Mg (phosphorus)/g (protein)	10.2	15	11.1	6.6	7.3	6.4	12.6	16.7