Secondary hyperparathyroidism (SHPT) in chronic kidney disease is managed by controlling the disturbances that drive PTH excess. Calcimimetics are central: oral cinacalcet lowers PTH without raising calcium or phosphate (in a landmark trial, far more patients reached target PTH than with placebo), and the intravenous calcimimetic etelcalcetide is convenient for in-center hemodialysis patients by allowing administration at the end of dialysis. Active vitamin D analogues (calcitriol, paricalcitol) remain first-line in non-dialysis patients with severe progressive disease, balanced against the risk of hypercalcemia and hyperphosphatemia, and extended-release calcifediol offers a more physiologically regulated way to raise vitamin D and lower PTH in non-dialysis CKD. Phosphate control is essential, with newer options such as the phosphate-absorption inhibitor tenapanor complementing traditional binders. Parathyroidectomy remains important for severe SHPT refractory to medical therapy, reducing symptoms and improving cardiovascular and survival outcomes.
Further reading: cinacalcet for SHPT (Block et al., NEJM 2004); SHPT management in non-dialysis CKD (Ketteler et al., NDT 2023); US practice patterns Delphi panel (Henner et al., 2025).