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Treatment of hyperphosphatemia: the dangers of aiming for normal PTH levels

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Abstract

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.

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Authors and Affiliations

  1. Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany

    Dieter Haffner & Maren Leifheit-Nestler

  2. Pediatric Research Center, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany

    Maren Leifheit-Nestler

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  1. Dieter Haffner
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Correspondence to Dieter Haffner.

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DH and MLN received a research grant from Amgen. DH received consultant fees from Amgen.

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Haffner, D., Leifheit-Nestler, M. Treatment of hyperphosphatemia: the dangers of aiming for normal PTH levels. Pediatr Nephrol 35, 485–491 (2020). https://doi.org/10.1007/s00467-019-04399-0

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  • DOI: https://doi.org/10.1007/s00467-019-04399-0

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