PTH and metabolic acidosis: Metabolic acidosis is another strong stimulus for secondary hyperparathyroidism, [20] and the blood concentration of the intact parathyroid hormone has been shown to be higher in hemodialysis patients with sodium bicarbonate supplementation than in those without supplementation therapy (P < .001).[21] Further studies will be required to delineate the complex interactions between the risk of developing TP and hyperparathyroidism in hemodialysis patients.