This protocol addresses patients with chronic kidney disease (CKD G3a–G5) who are not on dialysis and whose intact PTH is progressively rising or persistently above the upper normal limit for the assay. In this population, the optimal PTH level is not established; however, a rising or persistently elevated intact PTH requires structured evaluation and a defined clinical response.
Initial management targets correcting modifiable factors: reducing dietary phosphate intake, administering phosphate binders, calcium supplements, and/or native vitamin D, and correcting vitamin D deficiency. This protocol applies when those measures have not stopped intact PTH from rising progressively, and targets for phosphate balance, calcium, and vitamin D status remain unmet.
For patients who meet specific eligibility criteria, a class of active vitamin D therapy is among the options described in the complete protocol. The conditions for initiating this therapy, the monitoring framework, and the decision algorithm are detailed in full — only a partial outline is provided here.
Suppression of intact PTH without inducing hypercalcemia.
DOI: 10.1038/ki.2009.191
In patients with CKD G3a–G5 not on dialysis, the optimal PTH level is not known.
However, we suggest that patients with levels of intact PTH progressively rising or persistently above the upper normal limit for the assay be evaluated for modifiable factors, including hyperphosphatemia, hypocalcemia, high phosphate intake, and vitamin D deficiency (2C).
It is reasonable to reserve the use of calcitriol and vitamin D analogs for patients with CKD G4–G5 with severe and progressive hyperparathyroidism (Not Graded).
If initiated for severe and progressive SHPT, calcitriol or vitamin D analogs should be started with low doses, independent of the initial PTH concentration, and then titrated based on the PTH response.
Hypercalcemia should be avoided.