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You are managing a 10-year-old girl with Stage 3b CKD. Her labs show normal serum calcium, normal serum phosphorus, and a 25-hydroxy vitamin D level of 35 ng/mL. However, her parathyroid hormone (PTH) level is progressively rising above the target range for her CKD stage. What is the earliest pathologic driver responsible for this rise in PTH?

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