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Recomendación 1:
En pacientes con ERC estadio 5D recomendamos usar una concentración de calcio en la solución de diálisis entre 1.25 y 1.50 mmol/L (2.5 y 3.0 mEq/L). (Recomendación fuerte a favor)

Recomendación 2:

• En pacientes con ERC estadio 3 – 5, sugerimos mantener el nivel de fósforo sérico en rango normal. En pacientes con estadio 5D, sugerimos disminuir los niveles elevados de fósforo sérico hacia niveles de rango normal.
• En pacientes con ERC estadio 3 – 5D, sugerimos mantener el calcio sérico dentro de rango normal.
• Sugerimos un valor permitido de fósforo hasta 5mg/dL y para calcio hasta 10mg/dL como objetivos de tratamiento.
  (Recomendación condicional a favor)

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Recomendación 1:

• En pacientes con ERC estadio 3 – 5, recomendamos usar agentes quelantes de fósforo en el tratamiento de la hiperfosfatemia progresiva o persistente. Y en pacientes con ERC estadio 5D, recomendamos usar agentes quelantes de fósforo en el tratamiento de la hiperfosfatemia. Es razonable que, en la elección del agente, se tome en cuenta el estadio de la ERC, presencia de otros componentes de los DMO – ERC, terapias concomitantes y efectos colaterales.
• Se recomienda el uso de quelantes no cálcicos sobre los quelantes cálcicos, debido que se asocian a un menor riesgo de mortalidad. (Recomendación fuerte a favor, certeza moderada de la evidencia)

Recomendación 2:

• En pacientes con ERC estadios 3 – 5D e hiperfosfatemia, sugerimos suspender los quelantes de fósforo basados en calcio, así como calcitriol y/o análogos de la vitamina D en presencia de hipercalcemia persistente o recurrente. En pacientes con ERC estadios 3 – 5D e hiperfosfatemia, aun sin hipercalcemia, sugerimos suspender los agentes quelantes de fósforo basados en calcio en presencia de calcificación arterial y/o enfermedad ósea adinámica y/o si el nivel de PTH sérico está persistentemente bajo.
• En pacientes con ERC estadios 3-5D e hiperfosfatemia, se sugiere suspender el uso de quelantes cálcicos en el caso de uso concomitante con vitamina D o análogos. (Recomendación fuerte a favor, certeza moderada de la evidencia)

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Recomendación 1:
Sugerimos que los pacientes con niveles de PTH intacta encima del límite superior normal, sean primero evaluados por hiperfosfatemia, hipocalcemia y deficiencia de vitamina D. Es razonable corregir estas anormalidades con cualquier o todas las siguientes: Reducir la ingesta dietética de fósforo y administrar agentes quelantes de fósforo, suplementos de calcio y/o vitamina D nativa. (Recomendación débil a favor, certeza muy baja de la evidencia)

Recomendación 2:

• En pacientes con ERC estadio 3-5D, sugerimos iniciar tratamiento cuando los valores de PTH se encuentren por encima de los valores objetivos.
• Sugerimos que los cambios marcados en los niveles de PTH en cualquier dirección, dentro de los límites de este rango, den lugar a iniciar o cambiar la terapia para evitar la progresión a niveles fuera de este rango. (Recomendación débil a favor, certeza muy baja de la evidencia)

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Recomendación 1:
En pacientes con ERC estadio 5D y PTH alta o en ascenso, sugerimos sean usados los activadores no selectivos de los receptores de la vitamina D (AnSRVD) o activadores selectivos de los receptores de la vitamina D (ASRVD) para disminuir la PTH. Para disminuir la PTH:

• Es razonable que la selección de la droga inicial para el tratamiento de la PTH elevada se base en los niveles séricos de calcio y fósforo y otros aspectos de la TMO – ERC.
• Es razonable que la selección de la droga inicial para el tratamiento de la PTH elevada sea calcitriol.
• Sugerimos que en caso de resistencia a calcitriol, consistente en niveles PTH>600 al uso de calcitriol (dosis máximas tolerables) después de seis meses, emplear ASRVD como paricalcitol.
• En los pacientes con HPTs y ERC 5D que presenten resistencia a fármacos de primera elección como calcitriol o paricalcitol, se recomienda realizar paratiroidectomía.
• En los pacientes con recomendación de paratiroidectomía, que tienen contraindicación para la cirugía o está retrasada más allá de los 30 días luego de ser declarado como apto para la cirugía por el cirujano, se sugiere el uso de cinacalcet.
• En presencia de calcificaciones vasculares sugerimos no utilizar
• Es razonable que la dosis de los agentes quelantes de fosfato basados y no basados en calcio se ajusten de manera que los tratamientos para controlar la PTH no comprometa los niveles de fósforo y calcio.
• Recomendamos que, en pacientes con hipercalcemia, el calcitriol u otro esterol de la vitamina D sea reducido o interrumpido.
• Sugerimos que, en pacientes con hiperfosfatemia, el calcitriol u otro esterol de la vitamina D sea reducido o interrumpido.
  (Recomendación condicional a favor)

Recomendación 2:
En pacientes con ERC estadios 3 – 5D con severo hiperparatiroidismo en quienes falla la respuesta a la terapia médica (farmacológica), sugerimos la paratiroidectomía. (Recomendación condicional a favor)

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Recomendación 1:
En pacientes con ERC en diálisis, sugerimos que la radiografía lateral de abdomen pueda ser usada para detectar la presencia de calcificaciones vasculares, como razonables alternativas a las imágenes basadas en tomografía computada (score Kauppila). (Recomendación condicional a favor)

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