The risk of medically uncontrolled secondary hyperparathyroidism depends on parathyroid hormone levels at haemodialysis initiation

Abstract

Background Optimal parathyroid hormone (PTH) control during non-dialysis chronic kidney disease (ND-CKD) might decrease the subsequent risk of parathyroid hyperplasia and uncontrolled secondary hyperparathyroidism (SHPT) on dialysis. However, the evidence for recommending PTH targets and therapeutic strategies is weak for ND-CKD. We evaluated the patient characteristics, treatment patterns and PTH control over the first year of haemodialysis (HD) by PTH prior to HD initiation. Methods We studied 5683 incident HD patients from 21 countries in Dialysis Outcomes and Practice Patterns Study Phases 4–6 (2009–18). We stratified by PTH measured immediately prior to HD initiation and reported the monthly prescription prevalence of active vitamin D and calcimimetics over the first year of HD and risk of PTH >600 pg/mL after 9–12 months on HD. Results The 16% of patients with PTH >600 pg/mL prior to HD initiation were more likely to be prescribed active vitamin D and calcimimetics during the first year of HD. The prevalence of PTH >600 pg/mL 9–12 months after start of HD was greater for patients who initiated HD with PTH >600 (29%) versus 150–300 (7%) pg/mL (adjusted risk difference: 19%; 95% confidence interval : 15%, 23%). The patients with sustained PTH >600 pg/mL after 9–12 months on HD were younger, more likely to be black, and had higher serum phosphorus and estimated glomerular filtration rates at HD initiation. Conclusions Increased PTH before HD start predicted a higher PTH level 9–12 months later, despite greater use of active vitamin D and calcimimetics. More targeted PTH control during ND-CKD may influence outcomes during HD, raising the need for PTH target guidelines in these patients.

Effects of parathyroidectomy on plasma PTH fragments and heart rate variability in stage 5 chronic kidney disease patients

“…Although great breakthroughs have been made in the treatment of SHPT, ESKD patients often display significant increases in PTH levels. PTH is synthesized and secreted by the parathyroids, which is a reliable marker of parathyroid function and plays an important role in mineral metabolism [ 21 ]. Accurate detection of the circulating PTH levels is essential for the clinical management of CKD-MBD.…”

Efficacy and safety of intravenous paricalcitol treatment in Chinese hemodialysis patients: a real-world database analysis

“…Only 1 case developed iPTH levels lower than 150 pg/mL, suggesting a smaller risk of dynamic bone disease during the treatment when paricalcitol. PTH elevations frequently (32) in CKD G3-4 (40% in CKD G3 and 80% in CKD G4) , and increased levels of PTH before HD start predicted a sustained increased PTH level at 1 year (33). Targeted iPTH control before dialysis may decrease the subsequent risk of parathyroid hyperplasia and uncontrolled SHPT on dialysis (33).…”

Personalized Prediction of Short- and Long-Term PTH Changes in Maintenance Hemodialysis Patients

“…However, despite PTH-lowering medication, about 30% of these patients do not achieve target levels. High PTH at dialysis initiation predicted higher PTH levels at 1-year follow-up despite higher doses of PTH-lowering medication ( 15 ). These findings highlight the relevance of iPTH history and dialysis vintage for the estimation of patient specific model parameters, i.e., individualization of the PTG model.…”