Clinical Practice Guideline for the Management of Secondary Hyperparathyroidism in Chronic Dialysis Patients

The kidney plays an important role in mineral metabolism; thus, in most chronic kidney disease (CKD) patients, various abnormalities of bone and mineral metabolism develop, depending upon the stage of the disease. It has been more widely recognized that deranged mineral metabolism in CKD results not only in bone diseases, but also in a higher risk of mortality, possibly through the development of vascular calcification. Accordingly, instead of the classic term “Renal Osteodystrophy (ROD),” a new term, “CKD-Mineral and Bone Disorders (CKDMBD),” has recently been proposed as a systemic disorder, with cardiovascular disease, fractures, and mortality as major outcomes (1). Secondary hyperparathyroidism is one of the most common abnormalities of CKD-MBD. Secretion of parathyroid hormone (PTH) is usually stimulated without appropriate correction of hypocalcemia, hyperphosphatemia, and decreased production of 1,25-dihydroxyvitamin D in CKD patients. In such patients, parathyroid hyperplasia, composed of cells with a decreased density of vitamin D and calcium-sensing receptors, develops over the long term, which leads to resistance to medical therapy and the development of extraosseous calcification. Furthermore, medical therapy itself may worsen hypercalcemia and hyperphosphatemia in advanced cases (2). Thus, it is quite important to prevent the development of parathyroid hyperplasia from the early stages of hyperparathyroidism (3). The Japanese Society for Dialysis Therapy (JSDT) clinical practice guideline for the management of secondary hyperparathyroidism in chronic dialysis patients was originally published in Japanese in 2006 (4). This article contains the guideline text and footnotes translated into English, and the background, rationales and practical explanations originally written for the English version. Members of the working group for the original version are listed in Appendix 1. Japanese dialysis patients have unique characteristics that are different from those of American and European patients, including a much lower mortality and longer dialysis duration; in addition, there has been a limited availability of new drugs in Japan (5). Accordingly, in order to establish guidelines for Japanese patients, we screened recent papers and reanalyzed the JSDT database, and tried to set the target range of parameters depending as much as possible upon the best survival rates. As in the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF K/DOQI) and other guidelines (6), the Japanese guideline is mainly based Received July 2008. Address correspondence and reprint requests to Dr Masafumi Fukagawa, Division of Nephrology and Kidney Center, Kobe University School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan. Email: fukagawa@med.kobe-u.ac. jp Reprinted with permission from: Japanese Society for Dialysis Therapy. Guidelines for the management of secondary hyperparathyroidism in chronic dialysis patients. J Jap Soc Dial Ther 2006; 39:1435–55 (in Japanese). Therapeutic Apheresis and Dialysis 12(6):514–525 doi: 10.1111/j.1744-9987.2008. 00648.x © 2008 The Authors Journal compilation © 2008 International Society for Apheresis