Critical Governance Issue of Parathyroid Hormone Assays and its Selection in the Management of Chronic Kidney Disease Mineral and Bone Disorders

Abstract

Measurement of circulating parathyroid hormone (PTH) levels is essential for optimal management of mineral and bone disorders (MBD) in chronic kidney disease (CKD) patients. There are two major types of PTH assays currently in use: intact parathyroid hormone (i-PTH) and whole PTH (w-PTH) assays. The i-PTH assay is the current standard, and considerable information regarding the management of CKD-MBD has been obtained with this method. However, several limitations have been found with the i-PTH assay. One limitation is that i-PTH assay also measures fragments other than full-length PTH (1-84). Another limitation is the existence of multiple readout methods of the i-PTH assay. The w-PTH assay is theoretically ideal because it exclusively detects full-length PTH (1-84). However, clinical data proving the advantages of w-PTH measurement are not sufficient. For uremic patients, Kidney Disease Improving Global Outcomes suggest that PTH levels should be maintained within approximately two to nine times the upper normal limit of the i-PTH assays. The most critical issue in the evaluation of PTH levels is the lack of definitive PTH assay method. Evidence-based recommendations on clinical management goals of PTH are warranted.

The Correlation between Estimated Glomerular Filtration Rate and Parathyroid Hormone Levels in Predialysis-chronic Kidney Disease Adult Patients at Sanglah General Hospital, Bali, Indonesia

“…Kidney Disease Improving Global Outcomes (KDIGO) 2017 recommends routine parathyroid hormone, calcium, and phosphate checks on CKD patients starting from stage 3-5 to prevent or delay complications related to CKD [14]. KDIGO also suggests that MBD-PGK management should be based on serial measurements of parathyroid hormone serum and the tendency to persistently increase parathyroid hormone levels above the upper limit of normal value has more clinical significance than just one measurement [15]. Based on those mentioned above, this study aims to analyze the correlation between e-GFR and parathyroid hormone levels in predialysis CKD patients undergoing treatment at Sanglah General Hospital.…”

Serum sirtuin 1 is independently associated with intact PTH among patients with chronic kidney disease

“…28 It should be stressed that routinely used second generation assay (iPTH) detects both (1-84)-PTH and (7-84)-PTH. 29 According to previous data, (7-84)-PTH accumulates progressively in the circulation along with eGFR decline, 30 therefore it may overestimate secondary hyperparathyroidism. Hence, iPTH assay may not sufficiently reflect PTHrelated VC and cardiovascular risk.…”

Parathyroid Hormone Fragments: New Targets for the Diagnosis and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder

“…Like other C-PTH fragments, (7-84)PTH can be both degraded from (1-84)PTH in the liver and secreted by the parathyroid glands [13]. These fragments accumulate in the circulation of CKD patients and account for up to 45-50% of all circulating PTH molecular forms because they are mainly cleared through the kidney [14]. Previous studies have demonstrated that (7-84)PTH and C-PTH fragments increase as the estimated glomerular filtration rate (eGFR) decreases [15].…”