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Watch Prof. Kielstein's NUE 2020 talk: expanding SHPT treatment horizons

30 September 2020

What are the latest developments in the management of SHPT in ND-CKD patients?

In this video presentation recorded at Nephro Update Europe (NUE) 2020, Professor Jan Kielstein* addresses the clinical challenges and expanding horizons of managing secondary hyperparathyroidism (SHPT) in non-dialysis chronic kidney disease (ND-CKD) patients. A link to the full video presentation is provided at the end of this article.

SHPT is associated with increased morbidity and mortality1,2

The majority of patients suffering from chronic kidney disease (CKD) are affected by mineral and bone disorder (CKD–MBD).3 Disturbances in mineral metabolism caused by declining kidney function lead to the development of SHPT.4

Professor Kielstein explains that SHPT, which is characterised by excessive secretion of parathyroid hormone (PTH) and hyperplasia of the parathyroid glands,4 is a progressive disease that manifests frequently and early in patients with CKD.3 In stage 3–4 CKD, if uncontrolled, SHPT can lead to an increased risk of bone disease, fractures and cardiovascular disease, with associated morbidity (including progression to dialysis1) and mortality.2

Target PTH and vitamin D levels in ND-CKD are unclear5,6

A number of challenges for SHPT management in ND-CKD patients remain, including:

  • No recognised target level for PTH currently exists.5 However, Kidney Disease: Improving Global Outcomes (KDIGO) recommends that ND-CKD patients should receive early and regular monitoring of PTH from grade 3A CKD to identify progressively rising or persistently elevated PTH levels above the upper limit of normal5
  • Whilst vitamin D (25-hydroxyvitamin D) insufficiency is recognised as a key modifiable risk factor for the development and progression of SHPT,5,6 target vitamin D levels are unclear.6 Emerging evidence suggests that vitamin D levels should be higher than current guideline targets in order to effectively control SHPT in ND-CKD patients6,7

The SHPT treatment horizon is expanding

Professor Kielstein considers the different therapeutic approaches to reducing PTH, noting that few agents are licensed for use in the ND-CKD SHPT setting, and optimal management in these patients has proven controversial.

He evaluates the use of a new 25D formulation in the treatment of SHPT in ND-CKD patients, the evidence for which helps to shine a light on what the target 25D level in ND-CKD patients should be.7 Based on the evidence, Professor Kielstein concludes that “50 [ng/mL] is the new 30.”

You can watch the full presentation by Professor Kielstein on the Streamed-up website.

 

Footnotes and references

*Director of Medical Clinic V, Hypertension and Nephrology, at the Tertiary Care and Teaching Hospital Braunschweig; Braunschweig, Germany.

 

1. Schumock G et al. Curr Med Res Opin. 2008;24:3037–48.

2. Geng G et al. Osteoporos Int. 2019;30:2019–25.

3. Levin A et al. Kidney Int. 2007;71:31.

4. Cunningham J et al. Clin J Am Soc Nephrol. 2011;6:913–21.

5. Kidney Disease: Improving Global Outcomes (KDIGO) Work Group. Kidney Int Suppl. 2017;7:1–59.

6. Ennis JL et al. J Nephrol. 2016;29:63−70.

7. Strugnell SA et al. Am J Nephrol. 2019;49:284–93.