Felsenfeld AJ, Jara A, Pahl M, Bover J, Rodriguez M
Differences in dynamics of parathyroid hormone secretion in hemodialysis patients with marked secondary hyperparathyroidism

J Am Soc Nephrol (Nov) 6:1371-1378 1995

These authors identified 21 patients with PTH levels >500 pg/ml (intact PTH, nl up to 65) and divided them into 2 groups with a serum calcium < 9 mg/dl (n=8) or >9 (n=13). They then compared the two groups response to PTH stimulation (using a dialysate calcium of 1 mEq/L) or PTH suppression (using a dialysate calcium of 4 mEq/L). They found that both in absolute numbers and percentages the hypocalcemic patients were more suppressible and less stimulatable. The authors were quite conservative in their interpretation, suggesting that the hypocalcemic patients might be more responsive to treatment, particularly with calcitriol.

Comment: I would extend these interpretations to say that the patients with hypocalcemia and high PTH are behaving quite physiologically and their PTH remains appropriate in its response. Such patients are quite liable to respond, therapeutically, to appropriate correction of their calcium by whatever means are used. In contrast, patients who have PTH elevation despite a normal or elevated calcium are already demonstrating, either because of size of gland or change to a more adenomatous picture, a state less likely to respond to medical therapy. (Sherrard)

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