Renal Secondary Hyperparathyroidism
0028 When renal function becomes compromised to such an
extent that creatinine, other nitrogenous metabolic
products, and Pi are retained abnormally and exces-
sively by the body, then several pathophysiological
adaptations occur that have serious effects on health.
One of the important adverse effects of the retention of
Pi is the rapid and progressive loss of mineral mass. The
chronic elevation of serum Pi causes a decline in serum
Ca
2þ
, which triggers PTH secretion. The net effect is a
constantly elevated PTH concentration that continues
to act on bone tissue, i.e., resorption, to try to raise
[Ca
2þ
] to its homeostatic set level. Since Pi is also
released from bone along with Ca
2þ
during resorption,
the serum Pi concentration also increases. Because the
kidneys cannot eliminate Pi adequately, [Ca
2þ
] can
never be raised to its set level, and bone tissue continues
to be degraded as part of an unending vicious cycle.
0029 Various dietary manipulations have been tried to
control the loss of bone mass, but no one regimen has
been very successful. Reductions of both dietary pro-
tein, especially animal protein, and phosphorus have
been moderately successful in slowing the progress of
chronic renal disease, but the diets are not very palat-
able or satisfying.
Conclusions
0030 Pi metabolism is much more complex than that of
calcium because of the many intracellular pathways
that utilize Pi ions at one stage or another. The cyto-
solic utilization of Pi is closely linked with that of
glucose for the formation of glucose 6-phosphate
and for triglyceride synthesis through glycerol
3-phosphate formation, as well as with other mol-
ecules, during the postprandial period. Pi is utilized
by cells for many diverse molecules, including regula-
tory peptides and phospholipids. Extracellular regu-
lation of Pi is closely associated with that of calcium
through PTH and other calcium-regulating hor-
mones. Under typical dietary conditions of excessive
phosphorus intake compared with calcium, i.e., low
Ca:P ratio, nutritional secondary hyperparathyroid-
ism and the long-term development of osteopenia are
likely to result. Food fortification with calcium and
calcium supplementation are common ways in which
the low Ca:P ratio can be minimized, but individual
behaviors aimed at selecting a diet higher in calcium
will be needed to overcome the adverse ratio (0.5),
despite calcium fortification and/or supplementation.
Renal secondary hyperparathyroidism, a serious con-
sequence of renal functional impairment, produces
severe bone loss because of altered homeostatic regu-
lation of Pi.
See also: Aging – Nutritional Aspects; Bone; Calcium:
Physiology; Carbohydrates: Requirements and Dietary
Importance; Cells; Cholecalciferol: Physiology; Dietary
Requirements of Adults; Energy: Measurement of Food
Energy; Hormones: Thyroid Hormones; Steroid
Hormones; Osteoporosis
Further Reading
Akesson K, Lau K-H, Johnston P, Iperio E and Baylink DJ
(1998) Effects of short-term calcium depletion and
repletion on biochemical markers of bone turnover in
young adult women. Journal of Clinical Endocrinology
and Metabolism 83: 1921–1927.
Anderson JJB and Garner SC (eds) (1996) Calcium and
Phosphorus in Health and Disease. Boca Raton, FL:
CRC Press.
Anderson JJB, Sell ML, Garner SC and Calvo MS (2000)
Phosphorus. In: Russell R et al. Present Knowledge in
Nutrition, 7th edn. Washington, DC: International Life
Sciences Institute.
Barger-Lux J and Heaney RP (1993) Effects of calcium
restriction on metabolic characteristics of premeno-
pausal women. Journal of Clinical Endocrinology and
Metabolism 76: 103–107.
Bringhurst FR (1989) Calcium and phosphate distribution,
turnover, and metabolic actions. In: DeGroot LJ (ed.)
Endocrinology, 2nd edn, vol. 2. Philadelphia, PA: WB
Saunders.
Brot C, Jorgensen N, Jensen LB and Sorensen OH (1999)
Relationships between bone mineral density, serum
vitamin D metabolites and calcium:phosphorus intake
in healthy perimenopausal women. Journal of Internal
Medicine 245: 509–516.
Calvo MS, Kumar R and Heath H III (1990) Persistently
elevated parathyroid hormone secretion and action in
young women after four weeks of ingesting high phos-
phorus, low calcium diets. Journal of Clinical Endocrin-
ology and Metabolism, 70: 1340–1344.
Calvo MS and Park YM (1996) Changing phosphorus
content of the U.S. diet: Potential for adverse effects on
bone. Journal of Nutrition 126: 1168S–1180S.
Harnack L, Stang J and Story M (1999) Soft drink
consumption among US children and adolescents: Nu-
tritional consequences. Journal of the American Dietetic
Association 99: 436–441.
Institute of Medicine, Food and Nutrition Board (1997)
Dietary Reference Intakes: Calcium, Phosphorus, Mag-
nesium, Vitamin D and Fluoride. Washington, DC:
National Academy Press.
Karkkainen M and Lamberg-Allardt C (1996) An acute
intake of phosphate increases parathyroid hormone se-
cretion and inhibits bone formation in young women.
Journal of Bone and Mineral Research 11: 1905–1912.
McKane WR, Khosla S, Egan KS et al. (1996) Role of
calcium intake in modulating age-related increases
in parathyroid function and bone resorption. Journal
of Clinical Endocrinology and Metabolism 81:
1699–1703.
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