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Watch a video about why the 25(OH)D target for SHPT should be increased

25 June 2021

A new video by Professor Kielstein explores the rationale for raising the target 25(OH)D level for treating SHPT in ND-CKD

In this educational presentation, Professor Kielstein* addresses the challenges and conundrum associated with treating secondary hyperparathyroidism (SHPT) in non-dialysis chronic kidney disease (ND-CKD) patients. The professor puts emphasis on the question, should the target 25-hydroxyvitamin D (25(OH)D) level for these patients be raised?

The conundrum of the KDIGO CKD–MBD guidelines

The treatment of SHPT in ND-CKD patients is associated with various challenges and unanswered questions, including the following:

  • What is the optimal parathyroid hormone (PTH) level for ND-CKD patients?
  • To what extent should the elevation of PTH be accepted as an adaptive response to loss of mineral and vitamin D homeostasis?
  • What is the target 25(OH)D level for ND-CKD patients with SHPT?

To confuse matters, clinical practice guidelines do not provide clear guidance. For example, Kidney Disease: Improving Global Outcomes (KDIGO):1

  • Acknowledges that the optimal PTH level for ND-CKD patients is unknown
  • Recommends that, for the management of SHPT, patients with persistently rising or consistently elevated PTH levels be evaluated for modifiable risk factors, including vitamin D deficiency
  • Suggests that, to reduce PTH levels, vitamin D deficiency should be corrected using treatment strategies recommended for the general population

As stressed by Professor Kielstein, this leads to a conundrum … If the parathyroid glands and the mineral and vitamin D metabolisms of patients with renal SHPT are altered, why recommend the vitamin D deficiency treatment strategies used for the general population?

The target 25(OH)D level for the general population can be as low as 30 ng/mL (75 nmol/L)2 or even 20 ng/mL (50 nmol/L).3 Such a low level is unlikely to reduce the PTH levels of CKD patients with SHPT. This supports the case for targeting a higher 25(OH)D level in this patient population.

To explore the rationale as to why the target 25(OH)D level for SHPT patients may need to be increased, watch the educational presentation below.

Are clinical guideline targets of 25(OH)D sufficiency too low for non-dialysis CKD patients?

 

Footnotes and references

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

 

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

2. Holick MF et al. J Clin Endocrinol Metab. 2011;96(7):1911–30.

3. Ross AC et al. J Clin Endocrinol Metab. 2011;96(1):53–8.