Secondary hyperparathyroidism: Defining a model of optimal management

Despite recognition of the severity of secondary hyperparathyroidism for pa tients with chronic renal failure, effective treatment continues to be elus ive. Whereas current management practices have attained a certain level of success, the majority of patients still achieve relatively poor parathyroid hormone (PTH) control. The complex nature of this disease necessitates car eful attention to a multitude of factors-specifically, calcium, calcitriol, and phosphorus, the major regulators of PTH. To produce satisfactory outco mes requires integrating the management of these various factors. However, many of the currently available therapeutic agents and practices target onl y one aspect of the disease, while either worsening or failing entirely to remedy other attendant aspects. The questions then become, how should we de fine optimal PTH management, and, more importantly, how do we achieve optim al patient outcomes? This article reviews the limitations of our current tr eatment practices and initiates a dialogue on the role of new therapeutic a gents-such as non-calcemic, non-phosphatemic vitamin D analogs, and non-cal cium-, non-aluminum-based phosphate binders-in establishing new treatment s trategies. In addition, utilizing new management practices-including treati ng predialysis patients and using alternative dialysis modalities-offers si gnificant hope that delaying or preventing the onset of secondary hyperpara thyroidism is finally within our grasp.