Secondary hyperparathyroidism: pathogenesis, disease progression, and therapeutic options

Clin J Am Soc Nephrol. 2011 Apr;6(4):913-21. doi: 10.2215/CJN.06040710. Epub 2011 Mar 31.

Abstract

Secondary hyperparathyroidism (SHPT) is a challenge frequently encountered in the management of patients with chronic kidney disease (CKD). Downregulation of the parathyroid vitamin D and calcium-sensing receptors represent critical steps that lead to abnormalities in mineral metabolism: high phosphate, low calcium, and vitamin D deficiency. These imbalances result in parathyroid hyperplasia and contribute to vascular calcification. New studies have established a central role for fibroblast growth factor 23 (FGF-23) in the regulation of phosphate-vitamin D homeostasis. FGF-23 concentration increases in CKD and contributes to SHPT. Achieving current targets for the key mineral parameters in the management of SHPT set by the Kidney Disease Improving Global Outcomes (KDIGO) guidelines can be challenging. This review summarizes the current understanding and evidence supporting strategies for SHPT treatment in CKD patients. Treatment should include a combination of dietary phosphorus restriction, phosphate binders, vitamin D sterols, and calcimimetics. Parathyroidectomy is effective in suitable candidates refractory to medical therapy and the standard against which new approaches should be measured. Future strategies may focus on the stimulation of apoptotic activity of hyperplastic parathyroid cells.

Publication types

  • Research Support, Non-U.S. Gov't
  • Review

MeSH terms

  • Calcimimetic Agents / therapeutic use
  • Calcinosis / etiology
  • Chronic Disease
  • Disease Progression
  • Fibroblast Growth Factors / physiology
  • Humans
  • Hyperparathyroidism, Secondary / etiology
  • Hyperparathyroidism, Secondary / therapy*
  • Hyperplasia
  • Kidney Diseases / complications
  • Parathyroid Glands / pathology
  • Phosphates / metabolism
  • Vascular Diseases / etiology

Substances

  • Calcimimetic Agents
  • Phosphates
  • Fibroblast Growth Factors
  • fibroblast growth factor 23