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Uncontrolled secondary hyperparathyroidism in a haemodialysis patient Jordi Bover, MD, PhD Fundaci Puigvert Barcelona, Spain Springer Healthcare, a part of Springer Science+Business Media; 2010.Springer HealthcareSpringer Science+Business Media Slide 2 Objectives The systemic manifestations of chronic kidney disease- mineral bone disorder (CKD-MBD) The treatment of uncontrolled secondary hyperparathyroidism in CKD CKD: chronic kidney disease; CKD-MBD: chronic kidney disease-mineral and bone disorder Springer Healthcare, a part of Springer Science+Business Media; 2010.Springer HealthcareSpringer Science+Business Media Slide 3 Chronic kidney disease-mineral and bone disorder Chronic kidney disease-mineral and bone disorder (CKD-MBD) is a systemic disorder of mineral and bone metabolism due to CKD manifested by either one or more of the following: Abnormalities of calcium, phosphorus, PTH, or vitamin D metabolism Abnormalities in bone turnover, mineralisation, volume, linear growth, or strength Vascular or soft tissue calcification Several biochemical abnormalities of CKD-MBD are associated with reduced survival in dialysis patients Calcium, phosphate, PTH, Ca x P, alkaline phosphatase, FGF-23 Combinations of high-low PTH, calcium and phosphate Time on target Ca x P: calcium/phosphate product; CKD: chronic kidney disease; CKD-MBD: chronic-kidney disease-mineral and bone disorder; FGF-23: fibroblast growth factor-23; PTH: parathyroid hormone KDIGO CKD-MBD Work Group. Kidney Int. 2009 [Supp113]:S1130 Springer Healthcare, a part of Springer Science+Business Media; 2010.Springer HealthcareSpringer Science+Business Media Slide 4 Secondary hyperparathyroidism in CKD Secondary hyperparathyroidism is a common complication of impaired renal function Secondary hyperparathyroidism is associated with clinical complications involving the bones and other tissues Bone disease (renal osteodystrophy) is present in at least 70% of CKD patients starting dialysis, although different patterns have been observed over time Increased PTH is also associated with several uraemic conditions Treatment in secondary hyperparathyroidism aims to manage levels of calcium, phosphate and PTH Conventional therapy includes dietary reduction of phosphate intake, the use of phosphate binders, hydroxylated vitamin D sterols or the synthetic vitamin D analogue paricalcitol, and modification of the dialysis regimen Calcimimetics increase the sensitivity of calcium-sensing receptors to extracellular calcium ions, thereby inhibiting the release and synthesis of PTH Can be used as part of a therapeutic regimen including phosphate binders and/or vitamin D sterols, as appropriate CKD: chronic kidney disease; PTH: parathyroid hormone National Institute for Health and Clinical Excellence. January 2007 Springer Healthcare, a part of Springer Science+Business Media; 2010.Springer HealthcareSpringer Science+Business Media Slide 5 Patient presentation A 72-year-old female patient CKD stage 5D since 2007 Uncontrolled secondary hyperparathyroidism Current therapy Paricalcitol: 10 g/haemodialysis Sevelamer: 4800 mg/day Haemodialysis treatment (early morning shift) Kt/V 1.4 Dialysate calcium: 3 mEq/L CKD: chronic kidney disease Springer Healthcare, a part of Springer Science+Business Media; 2010.Springer HealthcareSpringer Science+Business Media Slide 6 Multiple choice question 1 According to the KDIGO 2009 guidelines and the KDOQI US Commentary on the 2009 KDIGO Clinical Practice Guidelines, which of the following is an important laboratory parameter for monitoring secondary hyperparathyroidism in patients with CKD stage 5D? A.Corrected serum calcium B.Serum phosphorus C.Alkaline phosphatase D.Intact parathyroid hormone E.All of the above Springer Healthcare, a part of Springer Science+Business Media; 2010.Springer HealthcareSpringer Science+Business Media Slide 7 Laboratory values for key secondary hyperparathyroidism parameters ParameterValueKDOQI 2003 Goals KDIGO 2009 Range Corrected calcium (mg/dL)10.18.4-9.5N Phosphate (mg/dL)5.63.5-5.5towards N Calcium/phosphate product (mg 2 /dL 2 ) 56.62-