Secondary and tertiary hyperparathyroidism in mineral and bone disease against the background of chronic kidney disease (36 hours)

Relevance.
Epidemiological studies show that suboptimal vitamin D levels, along with metabolic disorders (atherosclerosis, overweight, diabetes, hypertension), iodine deficiency diseases, and osteoporosis, are a major public health problem.
Changes in phosphorus-calcium metabolism often accompany chronic kidney disease. It was found that an increase in parathyroid hormone and a decrease in vitamin D are observed already from the 2nd stage of chronic kidney disease, despite the normal concentrations of calcium and phosphorus in the blood serum. Unfortunately, the lack of screening in the population of patients prone to the development of secondary hyperparathyroidism complicates the assessment of its prevalence and misses the period of prevention of severe complications of phosphorus-calcium metabolism. In case of untimely initiation of conservative treatment or in the case of incorrectly selected methods, secondary hyperparathyroidism resistant to drug therapy and complications associated with it are formed. After kidney transplantation, there is not always an involution of the altered glands (depending on the form of cell hyperplasia), which leads to the formation of tertiary hyperparathyroidism. 
In 2006, in the Kidney Disease Improving Global Outcomes Initiative (KDIGO), mineral disorders, together with impaired bone renewal and mineralization, the development of vascular calcification or other soft tissues, were combined into the concept of mineral-bone disease in chronic kidney disease. The association of osteodystrophy with hyperparathyroidism has long been known. Renal osteodystrophy is one of the severe bone lesions associated with kidney pathology and renal replacement therapy. Osteodystrophy is characterized by a complex and multifactorial pathogenesis, changes in the morphology of bone tissue and, to a large extent, determines the decline in the quality of life and disability of patients with chronic kidney disease. Given the versatility of osteodystrophy and the presence of reduced renal function, the choice of treatment for osteopathies is a complex clinical problem.
Numerous studies have demonstrated that ectopic (extra-skeletal) calcification — another manifestation of bone mineral disorders, is associated with increased hospitalization, overall mortality, and the risk of bone fractures. 
To date, there is a gap between the global and local practice of diagnosis and treatment of bone mineral disorders, there is a significant need for a single method to comply with the guidelines and practices for the management of patients with chronic kidney disease.
As part of the advanced training, doctors will master the latest achievements in the field of diagnosis of mineral and bone disorders; tactics of treatment and observation of patients with various forms of hyperparathyroidism in chronic kidney disease. The program includes methods of diagnosis, differential diagnosis of various forms of hyperparathyroidism and other disorders of phosphorus-calcium metabolism, as well as features of the diagnosis of complications of hyperparathyroidism. Special attention is paid to the possibility of drug correction of disorders of phosphorus-calcium metabolism in chronic kidney disease, and in the formation of resistance of hyperparathyroidism to drug therapy – radical treatment (percutaneous injections of ethanol, vitamin D activators; various volumes of parathyroidectomy) and approaches to the management of the postoperative period. 

The purpose of the additional professional educational program is to improve the theoretical knowledge and practical skills in the field of phosphorus-calcium disorders (hyperparathyroidism, hypoparathyroidism, osteodystrophy, ectopic calcification, etc.) in chronic kidney disease, necessary for professional activity, and to improve the professional level within the existing qualifications.
The content of the program covers the entire volume of theoretical knowledge and practical skills necessary for a doctor to conduct independent medical work with patients who have disorders of phosphorus-calcium, bone metabolism due to chronic kidney disease.

As part of the course, we:

1. Let's analyze the general principles and provisions of the regulation of phosphorus-calcium metabolism in normal and in the presence of a patient with chronic kidney disease;
2. We will analyze the current world and Russian clinical recommendations on bone metabolism, secondary and tertiary hyperparathyroidism against the background of chronic kidney disease;
3. We will analyze the methods of examination of patients with disorders of phosphorus-calcium metabolism: 
   - a complex of laboratory tests of blood and urine for the differential diagnosis of various forms of hyperparathyroidism and other disorders of phosphorus-calcium metabolism in the absence or presence of chronic kidney disease, at all its stages, as well as after kidney transplantation; 
   - a complex of examination of patients to determine the topical diagnosis of the affected parathyroid glands (ultrasound, scintigraphy with technetril, MSCT with contrast, puncture biopsy with a study of flushing from the needle for parathyroid hormone); 
   - complex examination of patients to identify complications of hyperparathyroidism from the bone tissue (densitometry, radiography, biopsy of trabecular bone tissue); 
   - complex examination of patients to identify complications of hyperparathyroidism from the cardiovascular system (radiography, multispiral computed tomography, echo cardiography, magnetic resonance imaging, intracoronary ultrasound); 
4. We will discuss modern aspects of pharmacological correction of disorders of phosphorus-calcium metabolism, secondary and tertiary hyperparathyroidism, and renal osteodystrophy. We will analyze the positive and negative effects of drug therapy on ectopic calcification; osteodystrophy. 
5. We will analyze the general indications and contraindications for surgical treatment in various forms of hyperparathyroidism (types of parathyroidectomies, percutaneous injections of ethanol and vitamin D activators). We will discuss the principles of postoperative management of patients. 
6. We will devote time to discussions, discussion of clinical examples and questions. 

Internship base: Endocrinology Department of the State Medical Institution of the Moscow State Medical Center named after A. S. Loginov DZM.
Internship Supervisor: Yegshatyan Lilit Vanikovna, Senior Researcher of the Department of Endocrinology of the State Medical Institution of the Moscow State Medical Center named after A. S. Loginov DZM.