Management of Bone Disease, Calcium, Phosphate and Parathyroid Hormone

(Suggestions are based on Level III and IV evidence) • Vitamin D therapy should be avoided when serum phosphate and/or calcium levels are significantly elevated, in order to reduce the risk of further elevation of calcium ¥ phosphate product and excess vascular and extravascular calcification. • Patients on vitamin D therapy must have regular monitoring of serum calcium, phosphate and PTH levels. • Oral calcitriol is effective for prevention or treatment of hyperparathyroidism in most patients on haemodialysis (HD) or peritoneal dialysis (PD). • Oral calcitriol can be effectively used either daily or less frequently as pulsed therapy, although there is insufficient evidence to say that the latter is superior to the former, either in terms of lowering PTH or reducing adverse effects. • Intravenous calcitriol may be more effective at lowering PTH levels and be less likely to cause hypercalcaemia, but the lack of well-designed studies of sufficient size prevent a more definitive statement. • Consideration may be given to using intravenous calcitriol when high PTH levels are resistant to oral calcitriol, or if patient compliance with self-administered oral calcitriol is in doubt. • Vitamin D analogues are effective at lowering PTH, but human studies proving their effectiveness with fewer side-effects (hypercalcaemia and/or hyperphosphataemia) are either lacking or are not definitive. On the basis of current evidence, there is little reason to recommend their use over either conventional oral calcitriol or intravenous calcitriol. • Use of alternatives to oral calcitriol (intravenous or the vitamin D analogues) needs to be balanced against their significantly higher costs.