OBJECTIVES Budget impact analysis (BIA) of the use of paricalcitol versus alternative treatment for the management of secondary hyperparathyroidism (SHPT) in end stage renal disease patients.  METHODS A Markov model was used to simulate the evolution of end stage renal disease patients trough transplant and death and to estimate associated direct health costs comparing the use of paracalcitol and cinacalcet plus low dose vitamin D over a 5-years horizon and using the Italian National Health System perspective. The model was developed using parameters from literature and assumption discussed with clinicians. National tariffs and costs from literature were used to value drug use, dialytic treatment, hospitalizations and transplant. One-way sensitivity analyses for model inputs were conducted. Costs and effects were discounted at 3% annum.  RESULTS Considering 13.311 candidate subjects for each treatment strategy, results from the model showed a decrease in direct healthcare costs from 1.782.921.351 Euro to 1.622.357.209 Euro in favour of paricalcitol over 5 years. Particularly, paricalcitol produced an overall saving in drug costs for more than 51 millions Euro while the other direct health costs related to dialysis, hospitalization and transplant were reduced by approximately 109 millions Euro. CONCLUSIONS In light of the high economic burden of end stage renal disease mainly associated with dialysis and transplant the use of paricalcitol for the treatment of IPTS in these patients represents a valid alternative not only from a clinical point of view but also from an economic point of view.