Llach F, Hervas J, Cerezo S
The importance of dosing intravenous calcitriol in dialysis patients with severe hyperparathyroidism

Am J Kidney Dis (Nov) 26:845-851 1995

These investigators studied the response of 10 dialysis patients with very severe hyperparathyroidism (intact-PTH = 1826 +/- 146 pg/ml; normals < 65). They used very high doses of calcitriol (up to 6.0 mcg IV three times a week) and achieved striking results (mean PTH at end of study was 211 +/- 48). Initial vitamin D dose was determined by the height of the initial PTH level and subsequent dose adjustments were made based on the PTH response. If PTH did not decline after 1 to 2 weeks, the dose of calcitriol was increased. When PTH declined by 25-30%, the calcitriol dose was decreased. By the end of the study (48 weeks) PTH was down approximately 90% while the calcitriol dose remained at 1.2 mcg after each dialysis. The authors noted hyperphospahtemia and hypercalcemia rarely and attributed this to careful diet monitoring, low calcium dialysate (2.5 mEq/L) and use of calcium acetate. They contrasted their results to that of Rao Sudhaker, et al (study in press) in which phosphate control was not so good and in which the PTH response was much poorer.

Comment: This last point is both the strength and weakness of the study. Much recent data confirm the necessity for good phosphate control to achieve PTH control. The unresolved question is how to achieve this. For many patients in this state, such good phosphate control is not possible (that is why they got into trouble in the first place) and hyperphosphatemia limits the use of calcitriol therapy. If phosphate can be controlled as well as Llach et al have done in this study, most of us should see similar responses. In my own experience, this degree of control is very difficult to achieve in most such patients. (Sherrard)

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