Treatment of hyperphosphatemia: the dangers of high PTH levels

  • Justine BacchettaEmail author
Pro/Con Debate
Part of the following topical collections:
  1. What’s New in Chronic Kidney Disease


The control of secondary hyperparathyroidism (SHPT) in pediatric chronic kidney disease is of utmost importance. Even though parathyroid hormone (PTH) is an important biomarker of mineral and bone disorders associated to CKD (CKD-MBD), calcium, phosphate, alkaline phosphatase, and vitamin D are also crucial and should be assessed together. In pediatric dialysis, high PTH levels have been associated with impaired longitudinal growth, bone disease, cardiovascular comorbidities, left ventricular hypertrophy, anemia, and even mortality (when PTH levels were above 500 pg/mL, i.e., 8.3-fold the upper normal limit (UNL)). As such, high PTH levels are for sure deleterious, but too low PTH levels have also been shown to impair growth and to promote vascular calcifications because of the underlying adynamic bone. This manuscript is part of a pros and cons debate for keeping PTH levels within the normal range in pediatric CKD, focusing on the pros. High bone turnover lesions can occur at lower PTH levels than “current” guidelines would suggest; thus, PTH alone is not a good predictor of the underlying osteodystrophy. PTH results can vary locally depending on the assay. Existing guidelines for PTH targets are conflicting and based on a very little evidence. However, the 120–180 pg/mL (2- to 3-fold the UNL) range is common to most of the guidelines; it seems to be a reasonable target in children undergoing dialysis, even though it does not correspond to “normal” PTH levels. As always, the philosophy of PTH levels in pediatric dialysis may be balanced, i.e., “not too low, not too high, and keep phosphate under control.”


Calcium CKD-MBD Children Dialysis Growth Osteodystrophy Phosphate PTH Vascular calcifications Vitamin D 



JB would like to acknowledge Bruno Ranchin, MD, Hôpital Femme Mère Enfant, Bron, France, for his careful review of this manuscript.

Funding information

JB received consultancy and speaker fees from Amgen and Vifor, and research grants from Amgen and Crinex.


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© IPNA 2019

Authors and Affiliations

  1. 1.Centre de Référence des Maladies Rénales Rares, Centre de Référence des Maladies Rares du Calcium et du PhosphoreHôpital Femme Mère EnfantBron CedexFrance
  2. 2.Université de LyonLyonFrance
  3. 3.INSERM 1033 Research UnitUniversité de LyonLyonFrance

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