A 52-year-old woman with chronic kidney disease stage 4 presents with serum calcium 7.2 mg/dL, phosphate 5.8 mg/dL, and PTH 420 pg/mL. A 58-year-old man with primary hyperparathyroidism presents with serum calcium 11.8 mg/dL, phosphate 2.1 mg/dL, and PTH 185 pg/mL. Which feature best discriminates secondary hyperparathyroidism (CKD) from primary hyperparathyroidism?

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