Cinacalcet sHPTH Hypercalcaemia Strategy — ESENeph MCQ

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ModerateHaemodialysisCinacalcet sHPTH Hypercalcaemia StrategyESENeph

A 65-year-old man with CKD G5D on haemodialysis has persistent hyperphosphataemia (phosphate 2.6 mmol/L) and PTH 95 pmol/L (KDIGO target 2-9x upper limit of normal). Calcium is 2.55 mmol/L. He is on sevelamer and calcitriol. What is the most appropriate next step?

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Correct answer: A — Reduce calcitriol and start cinacalcet

This patient has secondary hyperparathyroidism with concurrent hypercalcaemia (2.55 mmol/L) and hyperphosphataemia. The hypercalcaemia is likely driven by calcitriol. Continuing or increasing calcitriol will worsen hypercalcaemia and calcium-phosphate product. The appropriate strategy is to reduce calcitriol dose (addressing hypercalcaemia) and add cinacalcet (a calcimimetic that activates the calcium-sensing receptor on the parathyroid gland, suppressing PTH while lowering calcium). KDIGO CKD-MBD guidelines recommend cinacalcet for dialysis patients with sHPTH and hypercalcaemia where vitamin D analogues cannot be safely increased.

Reference: https://guidelines.ukkidney.org