Management of Elevated PTH and Hypertension

Diagnostic Evaluation

The American College of Physicians recommends measuring serum calcium levels to differentiate primary hyperparathyroidism from secondary hyperparathyroidism, with elevated or high-normal calcium indicating primary hyperparathyroidism and normal or low calcium indicating secondary hyperparathyroidism 1.
The National Kidney Foundation suggests checking 25-OH vitamin D levels, aiming for >20 ng/ml, as vitamin D deficiency is a common and reversible cause of secondary hyperparathyroidism 2, 1.
The European Renal Association recommends assessing dietary calcium intake through detailed dietary evaluation, as low urinary calcium excretion suggests calcium deprivation (calcium and/or vitamin D deficiency) 2, 3.
The American Society of Nephrology advises evaluating renal function with serum creatinine and estimated glomerular filtration rate (eGFR), as chronic kidney disease is a major cause of secondary hyperparathyroidism 1.

The Kidney Disease: Improving Global Outcomes (KDIGO) guideline recommends supplementing with native vitamin D if 25-OH vitamin D is below 20 ng/ml 2, 1.
The National Institutes of Health suggests ensuring adequate dietary calcium intake according to age-related recommendations: adults aged above 24 years should consume 950 mg daily 3, 4.
The European Society of Nephrology recommends adjusting the dose of active vitamin D and/or decreasing the dose of oral phosphate supplements to maintain PTH levels within normal range for patients on oral phosphate and active vitamin D therapy 2, 5.

The American College of Nephrology suggests considering calcimimetic therapy with cinacalcet in patients with severe hyperparathyroidism despite normocalcemia or in those with hypercalcemic hyperparathyroidism that has failed to respond to vitamin D and phosphate adjustments 2, 5.
The National Kidney Foundation warns that cinacalcet should be used with caution as it has been associated with severe adverse effects, namely hypocalcemia and increased QT interval 2.

The American Association of Endocrine Surgeons recommends considering parathyroidectomy in cases of persistent hypercalcemic hyperparathyroidism despite optimized medical therapy 2, 4.

The American College of Surgeons recommends surgical excision as the only definitive cure for primary hyperparathyroidism 6.

The European Renal Association advises monitoring for QT interval prolongation when using cinacalcet, particularly in patients with cardiac risk factors 2, 5.
The National Institutes of Health recommends avoiding reducing active vitamin D or phosphate supplements in patients with persistent hypercalciuria or hypercalcemia, as this can worsen nephrocalcinosis 2.