Hyperparathyroidism and chronic kidney disease. Part 2. Modern approaches to the prevention and treatment of secondary hyperparathyroidism. Lecture

Prevention and treatment of secondary hyperparathyroidism (SHPT) in patients with chronic kidney disease (CKD) is a complex problem. Excessive suppression of the parathyroid glands (PTG) leads to the development of hypoparathyroidism and adynamic bone disease. On the contrary, an underestimation of the severity of SHPT can lead to a further increase in blood parathyroid hormone (PTH), the development of disorders of mineral and bone metabolism, cardiovascular and other pathologies, and the formation of tertiary HPT. The modern approach to the correction of SHPT is aimed at personalized prevention of organ damage and the development of tertiary HPT, increasing medical and social rehabilitation and reducing mortality in patients. The therapeutic strategy for SHPT includes individual and simultaneous effects on the main pathogenic factors: hyperphosphatemia, hypocalcemia, vitamin D (calcidiol) deficiency/insufficiency, and excessive secretion of PTH. Control of hyperphosphatemia is essential for the control of SHPT. Current management options - diet and lifestyle changes, regular dialysis treatment, and use of phosphate binders have their benefits and limitations. Neutral calcium balance is maintained by diet, calcium supplements, vitamin D, and dialysate calcium. Native vitamin D has little efficacy in correcting SHPT in the pre-dialysis stage of CKD and is not recommended for dialysis patients. Vitamin D receptor activators (VDRAs) are widely used for the treatment of SHPT. However, VDRAs have calcemic and phosphatemic effects that limit their use to a subset of patients. VDRAs are prescribed to patients with CKD 4-5 st. with the progression of SHPT. A combination of VDRAs and a calcimimetic is recognized as the optimal strategy for SHPT in dialysis patients. Parathyroidectomy is performed in patients with refractory, drug-resistant SHPT. The indication for parathyroidectomy is not only the serum PTH level, which is not clearly defined but also clinical symptoms and HPT-associated complications. A modern therapeutic strategy should increase the effectiveness of the prevention and treatment of CKD-associated HPT.