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Treatment of hyperphosphatemia: the dangers of aiming for normal PTH levels.
Pediatric Nephrology ( IF 3 ) Pub Date : 2019-12-10 , DOI: 10.1007/s00467-019-04399-0
Dieter Haffner 1 , Maren Leifheit-Nestler 1, 2
Affiliation  

Secondary hyperparathyroidism is part of the complex of chronic kidney disease-associated mineral and bone disorders (CKD-MBD) and is linked with high bone turnover, ectopic calcification, and increased cardiovascular mortality. Therefore, measures for CKD-MBD aim at lowering PTH levels, but there is no general consensus on optimal PTH target values. This manuscript is part of a pros and cons debate for keeping PTH levels within the normal range in children with CKD, focusing on the cons. We conclude that a modest increase in PTH most likely represents an appropriate adaptive response to declining kidney function in patients with CKD stages 2-5D, due to phosphaturic effects and increasing bone resistance. There is no evidence for strictly keeping PTH levels within the normal range in CKD patients with respect to bone health and cardiovascular outcome. In addition, the potentially adverse effects of PTH-lowering measures, such as active vitamin D and calcimimetics, must be taken into account. We suggest that PTH values of 1-2 times the upper normal limit (ULN) may be acceptable in children with CKD stage 2-3, and that PTH levels of 1.7-5 times UNL may be optimal in patients with CKD stage 4-5D. However, standard care of CKD-MBD in children relies on a combination of different measures in which the observation of PTH levels is only a small part of, and trends in PTH levels rather than absolute target values should determine treatment decisions in patients with CKD as recommended by the 2017 KDIGO guidelines.

中文翻译:

高磷血症的治疗:达到正常PTH水平的危险。

继发性甲状旁腺功能亢进症是与慢性肾脏病相关的矿物质和骨骼疾病(CKD-MBD)的综合症的一部分,并与高骨骼更新,异位钙化和心血管死亡率增加有关。因此,针对CKD-MBD的措施旨在降低PTH水平,但对于最佳PTH目标值尚无普遍共识。该手稿是关于将CKD儿童的PTH水平保持在正常范围内的优缺点辩论的一部分,重点是缺点。我们得出的结论是,由于磷酸饱和作用和骨抵抗力的增加,PTH的适度增加很可能代表对CKD 2-5D期患者肾功能下降的适当适应性反应。就骨骼健康和心血管结局而言,尚无证据可将CKD患者的PTH水平严格保持在正常范围内。此外,必须考虑到降低PTH的潜在不利影响,例如活性维生素D和拟钙剂。我们建议CKD 2-3期患儿的PTH值是正常上限(ULN)的1-2倍是可以接受的,而CKD 4-5D期患儿的PTH水平是UNL的1.7-5倍可能是最佳的。然而,儿童CKD-MBD的标准治疗依赖于多种措施的组合,其中观察到PTH水平只是一小部分,并且PTH水平的趋势而非绝对目标值应决定CKD患者的治疗决策,因为由2017 KDIGO指南推荐。必须考虑到降低PTH的潜在不利影响,例如活性维生素D和拟钙剂。我们建议CKD 2-3期患儿的PTH值是正常上限(ULN)的1-2倍是可以接受的,而CKD 4-5D期患儿的PTH水平是UNL的1.7-5倍可能是最佳的。然而,儿童CKD-MBD的标准治疗依赖于多种措施的组合,其中观察到PTH水平只是一小部分,并且PTH水平的趋势而非绝对目标值应决定CKD患者的治疗决策,因为由2017 KDIGO指南推荐。必须考虑到降低PTH的潜在不利影响,例如活性维生素D和拟钙剂。我们建议CKD 2-3期患儿的PTH值是正常上限(ULN)的1-2倍是可以接受的,而CKD 4-5D期患儿的PTH水平是UNL的1.7-5倍可能是最佳的。然而,儿童CKD-MBD的标准治疗依赖于多种措施的组合,其中观察到PTH水平只是一小部分,并且PTH水平的趋势而非绝对目标值应决定CKD患者的治疗决策,因为由2017 KDIGO指南推荐。我们建议CKD 2-3期患儿的PTH值是正常上限(ULN)的1-2倍是可以接受的,而CKD 4-5D期患儿的PTH水平是UNL的1.7-5倍可能是最佳的。然而,儿童CKD-MBD的标准治疗依赖于多种措施的组合,其中观察到PTH水平只是一小部分,并且PTH水平的趋势而非绝对目标值应决定CKD患者的治疗决策,因为由2017 KDIGO指南推荐。我们建议CKD 2-3期患儿的PTH值是正常上限(ULN)的1-2倍是可以接受的,而CKD 4-5D期患儿的PTH水平是UNL的1.7-5倍可能是最佳的。然而,儿童CKD-MBD的标准治疗依赖于多种措施的组合,其中观察到PTH水平只是一小部分,并且PTH水平的趋势而非绝对目标值应决定CKD患者的治疗决策,因为由2017 KDIGO指南推荐。
更新日期:2020-01-17
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