Secondary Hyperparathyroidism in Chronic Kidney Disease

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Questions and Answers

What are the three factors the body employs to regulate calcium levels?

Glucagon, vitamin C, thyroid hormone

Parathyroid hormone, vitamin K, glucagon

Parathyroid hormone, vitamin D, calcitonin (correct)

Insulin, vitamin D, cortisol

What happens if the regulatory mechanisms for calcium fail?

Hypertension occurs

Decreased respiratory rate

Hypercalcemia or hypocalcemia can result (correct)

Increased heart rate

Which group of people is highlighted as potentially needing calcium supplements?

Elderly individuals

Adult men

Adolescent girls and postmenopausal women (correct)

Infants

What is the recommended approach to taking supplemental calcium?

Take just enough to make up the difference between diet intake and RDA Signup and view all the answers

Which food item does NOT serve as a good source of calcium according to the text?

Eggs Signup and view all the answers

What is the primary risk associated with excessive supplemental calcium intake mentioned in the text?

Vascular calcification, heart attack, stroke, kidney stones Signup and view all the answers

What is the primary function of osteoclasts in bone remodeling?

Break down old bone Signup and view all the answers

Which hormone promotes calcium resorption from bone and tubular reabsorption of calcium in the kidney?

Parathyroid hormone (PTH) Signup and view all the answers

How does vitamin D affect calcium levels in the body?

Increases calcium absorption from the intestine Signup and view all the answers

What is the main role of calcitonin in regulating calcium levels?

Inhibits calcium reabsorption by the kidney Signup and view all the answers

What are some symptoms of persistent and severe hypercalcemia?

Muscle weakness, fatigue, and anorexia Signup and view all the answers

How do the cells responsible for depositing new bone differ from those that resorb old bone?

They have opposite functions in bone remodeling Signup and view all the answers

What is the initial therapy for severe hypercalcemia?

Replacing lost fluid with intravenous saline Signup and view all the answers

Which drug is used to suppress PTH secretion in hypercalcemia associated with hyperparathyroidism?

Cinacalcet Signup and view all the answers

What is the most common disorder of calcium metabolism?

Osteoporosis Signup and view all the answers

What condition results from increased bone resorption and replacement of resorbed bone with abnormal bone?

Paget's disease Signup and view all the answers

Which disorder involves increased PTH secretion causing hypercalcemia and hypophosphatemia?

Primary hyperparathyroidism Signup and view all the answers

What are the common symptoms of hypoparathyroidism?

Parasthesias, tetany, laryngospasm Signup and view all the answers

What is the primary indication for vitamin D according to the text?

To improve bone health Signup and view all the answers

What is the primary source of obtaining natural vitamin D?

Oily fish like salmon Signup and view all the answers

What is the significance of 25(OH)D measurement as mentioned in the text?

It shows vitamin D deficiency status Signup and view all the answers

Under what conditions does the activation of vitamin D increase?

When plasma calcium levels decrease Signup and view all the answers

What is the recommended daily intake of vitamin D for adults aged 71 years and older according to the IOM guidelines?

800 IU/day Signup and view all the answers

What are the adverse effects of calcium salts mentioned in the text?

Hypercalcemia and hypocalcemia Signup and view all the answers

Which form of vitamin D is preferred because it is more effective than the other at raising blood levels of 25-(OH)D?

Cholecalciferol Signup and view all the answers

What is the primary treatment for Vitamin D toxicity?

Stopping vitamin D intake Signup and view all the answers

Which drug is a calcimimetic approved for primary hyperparathyroidism and secondary hyperparathyroidism caused by chronic kidney disease?

Cinacalcet (Sensipar) Signup and view all the answers

What is the effect of calcitonin on bone resorption?

It inhibits osteoclast activity and decreases bone reabsorption Signup and view all the answers

What are some adverse effects associated with bisphosphonates?

Esophageal cancer, atypical femur fractures, osteonecrosis of the jaw Signup and view all the answers

Which condition may be treated with bisphosphonates?

Postmenopausal osteoporosis Signup and view all the answers

What is the most widely used oral bisphosphonate mentioned in the text?

Alendronate Signup and view all the answers

How long should patients wait after taking alendronate before consuming calcium products, mineral supplements, or antacids?

2 hours Signup and view all the answers

For which condition is risedronate indicated?

Postmenopausal osteoporosis Signup and view all the answers

What is the dosing frequency for ibandronate for postmenopausal osteoporosis mentioned in the text?

Monthly Signup and view all the answers

Which mineral binds with alendronate and other bisphosphonates, requiring patients to wait before taking any supplements containing it?

Magnesium Signup and view all the answers

What is the primary adverse effect associated with alendronate and other bisphosphonates in terms of the esophagus?

Esophagitis Signup and view all the answers

What is the recommended post-dosing position for patients taking ibandronate for osteoporosis prevention?

Sitting up or standing Signup and view all the answers

Which adverse effect is NOT associated with risedronate usage mentioned in the text?

Constipation Signup and view all the answers

Which drug preserves bone mineral density and reduces plasma levels of cholesterol, similar to estrogen, but protects against breast and endometrial cancer?

Raloxifene Signup and view all the answers

Which drug is an analog of PTH that acts as a PTH agonist at PTH1 receptors, stimulating osteoblast activity to increase bone mass?

Abaloparatide Signup and view all the answers

Which drug, produced by recombinant DNA technology, is the only drug that increases bone formation?

Teriparatide Signup and view all the answers

Which drug is a first-in-class RANKL inhibitor used for osteoporosis in postmenopausal women and to prevent skeletal-related events in patients with bone metastasis?

Denosumab Signup and view all the answers

Which mineral binds calcium in the blood and rapidly reduces plasma levels of free calcium?

Edetate disodium Signup and view all the answers

Which drug should be consumed once a day for postmenopausal osteoporosis in the form of a combination tablet containing bazedoxifene and conjugated estrogens?

Bazedoxifene Signup and view all the answers

Which drug is an effective treatment for postmenopausal osteoporosis and has anticipated additional indications beyond this condition?

Abaloparatide Signup and view all the answers

Which drug stimulates osteoblast activity by acting as a PTH agonist at PTH1 receptors?

Teriparatide Signup and view all the answers

Which drug is used to prevent and treat postmenopausal osteoporosis while also reducing the risk for breast cancer?

Bazedoxifene Signup and view all the answers

Which drug is generally well-tolerated and has side effects that include nausea, headache, back pain, and leg cramps?

Teriparatide Signup and view all the answers

What is the primary purpose of using FRAX in osteoporosis management?

To predict an individual's 10-year fracture risk Signup and view all the answers

What is the main function of antiresorptive drugs in osteoporosis treatment?

Reducing osteoclast activity Signup and view all the answers

In osteoporosis management, what T-score range defines low bone mass (osteopenia)?

-1 to -2.5 Signup and view all the answers

Which of the following drugs is most effective at promoting bone formation in osteoporosis cases?

Teriparatide (Forteo) Signup and view all the answers

What T-score range signifies osteoporosis in BMD measurements?

-2.5 or greater Signup and view all the answers

What technique is recommended for measuring bone mineral density in osteoporosis diagnosis?

DEXA scan Signup and view all the answers

At what age does the NOF recommend BMD testing for all men?

70 and older Signup and view all the answers

Which group should be considered for osteoporosis treatment if they present with a T-score between -1 and -2.5 along with a 10-year probability of another major fracture of 20% or more?

(postmenopausal) Women and men aged 50 and older Signup and view all the answers

Which factor determines the success of antiresorptive drugs in osteoporosis treatment?

(Time) Early usage before substantial bone loss Signup and view all the answers

'What is the primary objective of osteoporosis treatment?' - This question stems from the text you provided.

To reduce fractures by maintaining or increasing bone strength. Signup and view all the answers

What distinguishes zoledronic acid from other bisphosphonates in the treatment of postmenopausal osteoporosis?

It is taken once a year or once every 2 years. Signup and view all the answers

What happens when osteoclasts ingest zoledronic acid?

It inhibits their activity. Signup and view all the answers

Why is estrogen replacement recommended for preventing bone resorption?

To decrease osteoclast proliferation. Signup and view all the answers

What is the advised daily dosage of low-dose estrogen for osteoporosis prevention?

0.3 mg/day Signup and view all the answers

Why is a progestin recommended for women with an intact uterus receiving estrogen replacement?

To minimize the risk of estrogen-induced endometrial cancer. Signup and view all the answers

What are the approved indications for zoledronic acid as stated in the text?

Hypercacemia of malignancy and GIOP Signup and view all the answers

How does zoledronic acid differ from other bisphosphonates in terms of dosing frequency?

It is administered once a year or once every 2 years. Signup and view all the answers

What role does zoledronic acid play in bone once it gets incorporated into it?

It inhibits osteoclast activity. Signup and view all the answers

What is the primary use of zoledronic acid according to the text?

Treatment of osteoporosis and hypercalcemia Signup and view all the answers

Study Notes

Calcium Physiology

Calcium is critical to the function of the skeletal, nervous, muscular, and cardiovascular systems
Two groups that may not get enough calcium from diet alone and may need supplements: adolescent girls and postmenopausal women
Recommended dietary allowance (RDA) for calcium varies by age group
Good sources of calcium include dairy products, tofu, broccoli, spinach, fortified orange juice, and fortified cereals
Over 98% of calcium in the body is stored in bone
Bone continuously undergoes remodeling, with osteoclasts breaking down old bone and osteoblasts laying down new bone

Regulation of Calcium Levels

Three factors regulate calcium levels: parathyroid hormone (PTH), vitamin D, and calcitonin
PTH promotes calcium resorption from bone, tubular reabsorption of calcium, and activation of vitamin D
Vitamin D increases calcium absorption from the intestine, decreases calcium excretion, and promotes calcium deposition in bone
Calcitonin lowers calcium levels by inhibiting bone resorption and increasing calcium excretion
Blood calcium levels are tightly controlled, with priority given to maintaining blood levels over bone levels

Hypercalcemia

Causes: cancer, hyperparathyroidism, vitamin D intoxication, sarcoidosis, and thiazide diuretics
Symptoms: weakness, fatigue, nausea, vomiting, anorexia, abdominal cramping, and constipation
Severe hypercalcemia can lead to kidney function impairment, seizures, and coma
Treatment involves promoting urinary excretion, decreasing bone resorption, and reducing intestinal absorption of calcium

Hypocalcemia

Causes: deficiency of PTH, vitamin D, or calcium, chronic renal failure, and medication use (e.g., magnesium-based laxatives, bisphosphonates)
Symptoms: neuromuscular excitability, tetany, convulsions, and spasms
Treatment involves intravenous calcium supplementation and oral calcium citrate

Osteoporosis and Paget's Disease

Osteoporosis: the most common disorder of calcium metabolism, characterized by decreased bone mass and increased fracture risk
Paget's disease: a chronic condition characterized by increased bone resorption and replacement with abnormal bone

Hyperparathyroidism

Causes: benign parathyroid adenoma, resulting in increased PTH secretion and hypercalcemia
Symptoms: skeletal muscle weakness, constipation, central nervous system symptoms, renal calculi, and bone abnormalities
Treatment involves surgical resection of the parathyroid glands and calcium-lowering drugs

Hypoparathyroidism

Causes: inadvertent removal of parathyroid glands during surgery
Symptoms: hypocalcemia, neuromuscular symptoms, and skeletal muscle spasms
Treatment involves calcium supplements and vitamin D

Vitamin D

Essential for bone health, owing to its effects on calcium utilization
Primary indications: vitamin D deficiency, rickets, osteomalacia, and hypoparathyroidism
Vitamin D increases calcium and phosphate levels, primarily by increasing their absorption from the intestine and promoting their resorption from bone

Bisphosphonates

Structural analogs of pyrophosphate that inhibit bone resorption by decreasing osteoclast activity
Indications: postmenopausal osteoporosis, osteoporosis in men, glucocorticoid-induced osteoporosis, Paget's disease of bone, and hypercalcemia of malignancy
Adverse effects: ocular inflammation, osteonecrosis of the jaw, atypical femur fractures, esophagitis, esophageal cancer, musculoskeletal pain, kidney failure, and atrial fibrillation### Bisphosphonates
Alendronate is the most widely used oral bisphosphonate and is used for prevention and treatment of osteoporosis in both men and women, glucocorticoid-induced osteoporosis, and Paget's disease.
Oral bioavailability of alendronate is poor.
Adverse effects of alendronate include esophagitis, and to reduce this risk, it should be taken with a full glass of water on an empty stomach, and the patient should remain upright for at least 30 minutes.
Minerals such as calcium, magnesium, and iron bind with alendronate and other bisphosphonates, so patients should wait at least two hours after administration before taking any calcium products, mineral supplements, or antacids.

Risedronate

Risedronate is indicated for postmenopausal osteoporosis, male osteoporosis, glucocorticoid-induced osteoporosis, and Paget's disease.
Adverse effects of risedronate include arthralgia, diarrhea, headache, rash, nausea, flu-like syndrome, esophagitis, atypical femoral fracture, ocular problems, and musculoskeletal pain.
Patients taking risedronate must remain upright for 60 minutes after taking.

Ibandronate

Ibandronate is used for prevention and treatment of postmenopausal osteoporosis.
Dosing of ibandronate can be done once a month or every three months, either orally or intravenously.
Adverse effects of ibandronate are the same as those of risedronate.
Oral dosing of ibandronate should be done on an empty stomach, and the patient should sit up or stand for 60 minutes after dosing, and avoid eating or drinking, including medications and dietary supplements.

Estrogen

Estrogen is most effective when initiated immediately after menopause, but treatment begun later in life can still offer significant protection.
If estrogen is discontinued, a period of accelerated bone loss will ensue.

Selective Estrogen Receptor Modulators (SERMs)

Raloxifene is a SERM that preserves bone mineral density (BMD) and reduces plasma levels of cholesterol.
Raloxifene is used to prevent and treat postmenopausal osteoporosis and to reduce the risk of breast cancer.
Adverse effects of raloxifene include thrombolytic events, fetal harm, and hot flashes.

Teriparatide

Teriparatide is a form of parathyroid hormone (PTH) produced by recombinant DNA technology.
It is the only drug that increases bone formation.
Teriparatide is indicated for treatment of osteoporosis in postmenopausal women, treatment of osteoporosis in men, and treatment of glucocorticoid-induced osteoporosis.
Main side effects of teriparatide are nausea, headache, back pain, and leg cramps.

Abaloparatide

Abaloparatide is an analog of PTH that acts as a PTH agonist at PTH1 receptors.
It is used for the treatment of postmenopausal osteoporosis.
The most common adverse effects of abaloparatide are increased uric acid levels, hypercalcemia, and erythema at the injection site.

Denosumab

Denosumab is a first-in-class receptor activator of nuclear factor kappa-B ligand (RANKL) inhibitor.
It is used for osteoporosis in postmenopausal women, men at high risk for fractures, bone loss in women and men receiving certain anti-cancer therapy, and prevention of skeletal-related events in patients with bone metastasis from solid tumors.
Adverse effects of denosumab include hypocalcemia, serious infections, dermatologic reactions, and osteonecrosis of the jaw.

Osteoporosis

Osteoporosis is a serious medical problem characterized by low bone mass, altered bone architecture, and increased bone fragility.
The risk for osteoporosis can be reduced by lifelong implementation of measures that can help maximize bone strength.
Lifestyle measures to help reduce the risk of osteoporosis include ensuring adequate intake of calcium and vitamin D, and adopting a lifestyle that promotes bone health.
Osteoporosis is diagnosed by measuring BMD, which is an important predictor of fracture risk.
The standard technique for measuring BMD is dual-energy x-ray absorptiometry (DEXA).

FRAX

FRAX is a web-based, interactive program that can assess an individual's 10-year risk for experiencing a fracture.
FRAX is available online at www.shef.ac.uk/FRAX/.
Postmenopausal women and men 50 years and older should be considered for treatment if they present with any of the following: a hip fracture or vertebral fracture; osteoporosis (T-score of −2.5 or less at the femoral neck or spine); or low bone mass (T-score between −1 and −2.5 at the femoral neck or spine) plus either a 10-year probability of a hip fracture of 3% or more or a 10-year probability of another major osteoporosis-related fracture of 20% or more, based on a US-adapted FRAX calculation.

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Description

Learn about the complications of secondary hyperparathyroidism in chronic kidney disease, including the treatment options and considerations. Explore the impact of vitamin D sterols, calcium-containing phosphate binding agents, and cinacalcet on mineral homeostasis.