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How is high turnover bone disease treated?
Treatment of this disorder entails prevention and correction of the factors leading to secondary hyperparathyroidism:
• Phosphorus control: dietary restriction, phosphate binders, adequate dialysis
• Prevention of hypocalcemia: oral calcium supplements, correction of vitamin D deficiency, dialysis
• Suppression of PTH production and secretion: vitamin D receptor activators (VDRA), including calcitriol, paricalcitol, and doxercalciferol, and/or the use of calcimimetics (cinacalcet, elecalcetide
Impact and Challenges With Vitamin D to Treat Secondary Hyperparathyroidism in Patients With Chronic Kidney Disease
| VITAMIN D COMPOUND | BIOLOGIC AND CLINICAL IMPACT | CHALLENGES |
|---|---|---|
| Ergocalciferol (D 2 ) Cholecalciferol (D 3 ) | Effective in repleting 25-D and 1,25-D in patients with early-stage CKD and adequate kidney function | Requires activation in the liver to generate 25-D Requires activation in the kidney to generate active 1,25-D Provides only partial suppression of PTH in patients with later-stage CKD |
| ER Calcifediol | Effective in repleting 25-D and 1,25-D in patients with CKD 3 and 4 Effectively suppresses SHPT | No data in CKD stage 5 |
| Calcitriol | Biologically active VDR agonist Effectively suppresses SHPT Reduces abnormal high bone turnover | Hypercalcemia, hypercalciuria, and hyperphosphatemia evident at high doses |
| Doxercalciferol | Suppresses SHPT similar to or better than calcitriol Noted reduction in serum bone-specific alkaline phosphatase and osteocalcin | Requires activation in liver to generate active 1,25-D Induces significant elevation of serum P, elevating need for phosphate binder use |
| Alphacalcidol | Suppresses SHPT similar to or better than calcitriol | Requires activation in kidney to generate active 1,25-D Induces significant elevation of serum P, elevating need for phosphate binder use |
| Paricalcitol | Biologically active VDR agonist Effectively suppresses SHPT Noted reduction in serum bone-specific alkaline phosphatase and osteocalcin | Minimal elevation in Ca, P, and Ca × P product, requiring Ca and P monitoring |
1,25-D , 1,25-Dihydroxyvitamin D; 25-D , 25-hydroxyvitamin; Ca , calcium; CKD , chronic kidney disease; ER , extended release; P , phosphorus; PTH , parathyroid hormone; SHPT , Secondary hyperparathyroidism; VDR , vitamin D receptor.
Surgical parathyroidectomy: in severe cases, parathyroidectomy may be required; however, bone biopsy should be considered prior to surgery
