A panel of US health care providers reached consensus on the major aspects of managing secondary hyperparathyroidism (SHPT) in chronic kidney disease (CKD) based on evidenced-based preferences and practical considerations, investigators reported at the European Renal Association – European Dialysis and Transplant Association (ERA-EDTA) Congress 2021.
In a modified, 3-phase Delphi process, David Henner, DO, of Berkshire Medical Center in Pittsfield, Massachusetts, and colleagues asked 10 health care providers (including 6 nephrologists) to address 126 questions on “typical” patients. In phase 1, individuals answered the questions electronically based on their own knowledge and experiences. In phase 2, providers were asked electronically if they would change their personal responses in light of the most common responses (defined as 66%). In phase 3, investigators convened a virtual meeting with all participants to resolve discrepancies through active discussion.
Of the 126 questions, 50% reached consensus by the end of phase 1, 92% by phase 2, and 100% by phase 3, the investigators reported.
“The panel unanimously agreed that SHPT treatment is often started too late and suggested additional markers for early identification of patients requiring treatment are needed,” Dr Henner’s team wrote. “Serum levels of calcium, phosphate, and parathyroid hormone should be monitored starting at CKD stage G3a at intervals of every 6 months, 3-6 months for CKD G3b, and at least every 3 months at CKD G4 and above.”
According to the consensus, clinicians should consider treating patients on dialysis when serum intact parathyroid hormone (PTH) exceeds 300 pg/mL, serum phosphate levels exceed 5.5 mg/dL, and/or serum calcium exceeds 9.5 mg/dL. Patients on dialysis were considered out of PTH target range at 8 times the upper limit of normal (more than 520 pg/mL).
Based on consensus findings, the panel preferred the intravenous calcimimetic etelcalcetide as first-line therapy for patients receiving in-center dialysis patients and oral cinacalcet for patients receiving home dialysis. Formularies and dialysis center protocols influenced their decisions.
Vitamin D therapy was recommended as first-line therapy for nondialysis-dependent CKD patients. Calcitriol and vitamin D receptor activators and, if necessary, parathyroidectomy were reserved for CKD stage 4 and 5 if PTH levels exceeded 1000 pg/mL.
The health care providers were concerned about vascular calcification in all patients. To avoid hypercalcemia and calciphylaxis, the panel recommended monitoring serum calcium during use of vitamin D therapies and not increasing dialysate calcium above 2.5 mEq/L, unless indicated. Hypocalcemia also warranted attention to avoid cardiac abnormalities.
Henner DE, Drambarean B, Gerbeling TM, et al. Practice patterns on the management of secondary hyperparathyroidism in the United States: results from a modified Delphi panel. Presented at the 58th ERA-EDTA Congress 2021, June 5-8, 2021. Abstract MO571.