Pharmacological Management of Secondary Hyperparathyroidism in Dialysis Patients: A Narrative Review of Calcimimetics, Vitamin D Analogs, and Phosphate Binders
Abstract
Secondary hyperparathyroidism (sHPT) is a prevalent complication of end-stage renal disease, driven by phosphate retention, vitamin D deficiency, hypocalcemia, and calcium-sensing receptor dysregulation. Despite international guidelines, optimal biochemical control remains challenging in real-world practice. This narrative review synthesizes current evidence on the pharmacological management of sHPT in dialysis patients, with attention to the underrepresented Middle Eastern and Gulf Cooperation Council (GCC) context. A narrative review was conducted using PubMed and Scopus, identifying original clinical studies, randomized controlled trials, and observational cohorts examining calcimimetics, vitamin D analogs, and phosphate binders in dialysis patients with sHPT. In total, 22 studies were included. Calcimimetics, particularly cinacalcet, reduce parathyroid hormone (PTH) by approximately 43% in hemodialysis patients without raising serum calcium, though hypocalcemia and gastrointestinal adverse effects limit tolerability. Intravenous etelcalcetide offers superior PTH suppression with improved gastrointestinal tolerability and eliminates oral adherence challenges through supervised dialysis-circuit administration. A large trial demonstrated no mortality benefit despite sustained PTH lowering. Vitamin D analogs suppress PTH gene transcription but carry a narrow therapeutic window with risks of hypercalcemia and hyperphosphatemia. Phosphate binders address the primary upstream…
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