Do you stop activated vitamin D (ie paricalcitol) in your dialysis patients who have hyperphosphatemia despite low phosphate diet and phosphorus binder adherence?

I usually don't unless their phosphorus is very high (>8) or if they are on very high doses of Vitamin D analogues, in which case, I trial a lower dose. In general, I don't think Vitamin D analogues contribute that much to higher phosphorus levels. Of course, if the phosphorus and PTH are both high then if the serum calcium is not low, calcimimetics should be the first line of therapy. It is also OK to trial a month off of the drugs to see if serum phosphorus improves, although this is hard to determine as there are so many factors affecting the serum phosphorus levels.