The most important etiological factors of resistance to medical treatments for secondary hyperparathyroidism are the decreased contents of the vitamin D receptor (VDR) and Ca-sensing receptor (CaSR) in parathyroid cells and a severely swollen parathyroid gland (PTG) as a result of hyperplasia. The effects of direct maxacalcitol (OCT) injection into PTG in terms of these factors were investigated in this study. The PTG of Sprague-Dawley rats that were 5/6 nephrectomized and fed a high-phosphate diet were treated by a direct injection of OCT (DI-OCT) or vehicle (DI-vehicle). The changes in serum intact parathyroid hormone (PTH), Ca
2؉, and phosphorus levels, in VDR and CaSR expression levels in parathyroid cells, and in Ca 2؉ -PTH curves were examined. Apoptosis was analyzed by the terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling method and DNA electrophoresis for PTG. DI-OCT markedly decreased serum intact PTH level, and a significant difference in this level between DI-OCT and DI-vehicle was observed. However, serum Ca 2؉ and phosphorus levels did not changed markedly in both groups. The upregulations of both VDR and CaSR, the clear shift to the left downward in the Ca 2؉ -PTH curve, and the induction of apoptosis after DI-OCT were observed. These findings were not observed in the DI-vehicle-treated rats. Moreover, these effects of DI-OCT were confirmed by the DI-OCT into one PTG and DI-vehicle alone into another PTG in the same rat. DI-OCT may introduce simultaneous VDR and CaSR upregulations and the regression of hyperplastic PTG, and these effects may provide a strategy for strongly suppressing PTH levels in very severe secondary hyperparathyroidism. S econdary hyperparathyroidism (SHPT) resulting from ESRD causes not only renal osteodystrophy but also cardiovascular disorders because of ectopic calcification in vascular tissues. A low level of parathyroid hormone (PTH) causes adynamic bone disease; easily increases serum calcium (Ca), phosphorus (P), and CaϫP levels; and may contribute to a poor prognosis in patients with ESRD. Thus, the maintenance of appropriate levels of PTH, Ca, and P is required for the improvement of the prognosis and quality of life of these patients (1-3).SHPT develops in conditions of P retention, low Ca level, and the inactivation of vitamin D (VD) (4 -6); therefore, the control of P level and supplementations of Ca and VD are necessary in patients with SHPT as preventive or medical treatment. However, advanced SHPT with severely swollen parathyroid glands (PTG) as a result of hyperplasia is resistant to these medical treatments because of the low contents of VD receptor (VDR) and Ca-sensing receptor (CaSR) in parathyroid cells (PTC) (7,8). When SHPT progresses into such status, it is considered irreversible. Thus, patients with very severe SHPT require parathyroidectomy-autotransplantation (PTx-AT), which may be complicated by some problems, such as the necessity of general anesthesia, the hyperor hypofunction of autotransplanted PTG, and mental suffering.The ...