The management of secondary hyperparathyroidism should be started at the beginning of CKD stage III (estimated GFR, <60 mL/min)

It is a complex process that requires good communication between the nephrologist, the dietitian, and the patient. It is important to recognize the treatment goals, which vary according to the stages of CKD. Serum levels of calcium, phosphorus, and intact PTH should be measured in all patients with CKD and estimated GFR <60 mL/min. The National Kidney Foundation K/DOQI guidelines provide frequency of measurements and goals for serum phosphorus and PTH according to CKD stage, listed below 14 (Table 2). The treatment of secondary hyperparathyroidism basically consists of a low phosphorus diet, phosphate binders, vitamin D derivatives, calcimimetics, and even parathyroidectomy.

Stepped Means

The goal of the first step is to optimize the levels of serum phosphorus and calcium (within the recommended ranges, depending on stage of CKD). This can be achieved by dietary restriction and the initiation of phosphate binders (calcium acetate, sevelamer, or lanthanum). In CKD stages III and IV, ergocalciferol should be considered if the 25-hydroxyvitamin D level is <30 ng/mL.

2 should concentrate on the control over PTH and you may supplement D levels by using calcimimetics and you can/or vitamin D analogues. In the event the calcium supplements and you will phosphorus account is around the upper limitation off regular, after that cinacalcet is highly recommended. At the same time, within calcium profile nearer to the reduced limit out of regular, vitamin D analogues could be a far greater choice.

Inside the step 3, the fresh amounts away from phosphate binders, calcimimetics, and nutritional D analogues will be modified to achieve the K/DOQI philosophy.

Low-Phosphorus Diet

To own clients with CKD grade III and you will IV (height B), the lowest-phosphorus eating plan would be started whenever serum phosphorus was over 4.6 mg/dL of course, if gel phosphorous is significantly more than 5.5 mg/dL into the clients having CKD phase V (peak Good), or if counted undamaged PTH try above the address variety of the CKD stage, even with typical levels of phosphorus and you may calcium supplements (peak A). Sadly, this is very difficult to go as phosphorus are omnipresent when you look at the our diet plan. Actually, the fresh weightloss phosphorus is mostly produced from dos supplies: dietary necessary protein and you can phosphorus ingredients. Such additives try an important part of processed foods such as for example meat, cheeses, dressings, drinks, and you can bakery factors. They could increase the weight loss phosphorus intake by as much as step 1 grams/go out. 15 Mineral constitution tables cannot through the phosphorus ingredients, which leads to underestimation out of phosphorus consumption. Moreover, the brand new phosphorus produced by herbs is within the sort of phytate that’s quicker absorbable by the person intestines because of an effective decreased the newest chemical phytase. Table cuatro portrays the fresh phosphorus stuff of some common meals that include necessary protein.

When you look at the a study of 30,076 clients on hemodialysis, Shinaberger ainsi que al 16 displayed that a premier-protein/low-phosphorus diet is with the top success, therefore the high mortality rates try utilized in clients on low-protein/low-phosphorus eating plan. This study shows the effect out-of weight-loss healthy protein toward survival out-of customers with the hemodialysis. The modern K/DOQI recommendations to own people having CKD should be maximum dieting phosphorus to help you 800 in order to one thousand mg/time, adjusted to possess slimming down necessary protein demands. 14

Phosphate Binders

Phosphate binders are definitely the mainstay of medication for supplementary hyperparathyroidism. The brand new noncompliance to help you fat reduction limit additionally the need to verify sufficient protein consumption usually make inclusion of phosphate binders in order to reduce web intake out-of weight loss phosphorus. During the a recent study had written when you look at the , patients treated with phosphate binders for the earliest 90 days once carrying out dialysis had a thirty% down chance of death compared with those who just weren’t handled. 17 Several methods was basically attempted, as well as aluminium hydroxide, calcium supplements salts, sevelamer hydrochloride (Renagel, Genzyme Corp., Cambridge, MA) and profil cupid lanthanum carbonate (Fosrenol, Shire United states, Inc., Wayne, PA).