PTH and hyperparathyroidism: The latest guideline states that “in adult patients with CKD G3a-G5...we suggest calcitriol and vitamin D analogs not be routinely used,” and states that “it is reasonable to reserve the use of calcitriol and vitamin D analogs for patients with CKD G4-G5 with severe and progressive hyperparathyroidism.”3 We find evidence that treating physicians, possibly as a result of these guidelines, appear to be using relatively high treatment thresholds: mean levels before treatment for PTH were 154, 221, and 352 pg/ml, respectively, for stages 3, 4, and 5 disease.