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Secondary Hyperparathyroidism — ESENeph MCQ

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ModerateHaemodialysisSecondary HyperparathyroidismESENeph

A 60-year-old man with CKD G5D on haemodialysis has a PTH of 120 pmol/L (reference 1.6-6.9). Calcium is 2.28 mmol/L and phosphate is 1.4 mmol/L. He is on maximal phosphate binder therapy and Alfacalcidol 1 mcg daily. Despite this, PTH continues to rise. What is the most appropriate next step?

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Correct answer: C — Start Cinacalcet

In dialysis patients with persistently elevated PTH despite active vitamin D, Cinacalcet (a calcimimetic) is recommended. KDIGO 2017 CKD-MBD update suggests using calcimimetics, calcitriol, or vitamin D analogues (or a combination) to lower PTH in dialysis patients with severe hyperparathyroidism (practice point). Cinacalcet reduces PTH without increasing calcium/phosphate. Parathyroidectomy is reserved for refractory cases. NICE TA117 supports Cinacalcet in uncontrolled secondary hyperparathyroidism where PTH >85 pmol/L.

Reference: KDIGO 2017 – CKD-MBD Update; NICE TA117 2007 – Cinacalcet for Hyperparathyroidism