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29 November 2021
In June 2021, Professor Michael Germain* gave an outstanding and advice-packed presentation that focused on practical approaches to managing secondary hyperparathyroidism (SHPT) in non-dialysis chronic kidney disease (ND-CKD) patients. As the highlight of his talk, he shared the strategy that he employed to treat SHPT in an ND-CKD patient from 2010 to 2021. The talk featured in a virtual symposium that Vifor Pharma hosted at the 58th European Renal Association–European Dialysis and Transplant Association (ERA–EDTA) Congress. The whole presentation has been published in the Emergency Medicine Journal (EMJ) for all to learn and benefit.
Professor Germain’s 11-year case offers important lessons in how to manage SHPT in a patient whose chronic kidney disease (CKD), SHPT and vitamin D insufficiency are progressing. It also emphasises the need for providing early and effective treatment.
The patient (Table 1) presented in 2010 with stage 3A CKD, arterial hypertension and diabetes mellitus, with presumed nephropathy. His serum calcium and phosphorus levels were normal, but his parathyroid hormone (PTH) level was mildly elevated. At this stage, no treatment for SHPT was prescribed.
Adapted from EMJ Nephrol. 2021.1
By 2017, the patient’s CKD had progressed to stage 4. His vitamin D level had dropped, and his PTH level had increased, necessitating treatment.
Professor Germain explains that, at this stage, his goal was not to normalise PTH but, instead, “to prevent it from progressing to the point of where it will become untreatable as the patient approaches/goes on to dialysis.”
To avoid or reduce the chances of developing refractory SHPT, Kidney Disease: Improving Global Outcomes (KDIGO) suggests that modifiable risk factors such as a low vitamin D level be addressed starting from stage 3A CKD.2 This also implies that, to detect SHPT and initiate treatment in an earlier rather than in a later stage, vitamin D and PTH levels need to be monitored more frequently.2
Sharing the patient's treatment journey, Professor Germain lays out the commonly used and new treatment options that he implemented starting from 2017, and how the patient responded. We learn that the patient’s vitamin D level initially remained low after starting vitamin D therapy. Possible reasons are outlined by Professor Germain.
Sufficient elevation of vitamin D and control of PTH without a clinically meaningful increase in serum calcium were finally established in 2021, after three different agents were tested.
You can read the full presentation by Professor Germain and get all the details about the treatment strategy he used in this 11-year patient case on the EMJ website. The presentation covers a wide range of topics, delving into the details of:
You can also watch the full ERA–EDTA 2021 symposium hosted by Vifor Pharma at the ERA–EDTA congress website.
Footnotes and references
*Baystate Medical Center, Springfield, Massachusetts, USA, and Tufts University School of Medicine, Boston, Massachusetts, USA.
EMJ Nephrol. 2021;9(1):30–8.
Kidney Disease: Improving Global Outcomes (KDIGO) Work Group. Kidney Int Suppl. 2017;1–59.
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