A case of secondary hyperparathyroidism in a patient on hemodialysis with parathormone levels within the targets and high total alkaline phosphatase

Chronic kidney disease related mineral and bone disorders (CKD-MBD) cause significant morbidity and mortality. Guidelines for treatment and prevention of CKD-MBD have put focus on the treatment of secondary hyperparathyroidism in patients on hemodialysis by maintaining levels of parathormone (PTH) between 2 to 9 times the upper normal limit. However, levels of PTH are not always accurately correlated to the degree of bone remodeling, and some patients may suffer from hyperparathyroidism though their PTH levels are within the targets. Therefore, it is important to identify other bone markers that could help us adequately assess bone status in these patients, such as total alkaline phosphatase (TALP). In this case report, we describe a patient who suffered from poorly controlled hyperparathyroidism with very high levels of TALP despite having PTH levels within the targets. TALP could thus be an important bone marker and should be taken into consideration complementary to PTH when evaluating the bone status of a patient on dialysis.