Other labs are revealed in table 2:
| Test | 2 years ago, |
| TSH | 0.9mU/l |
| Free T3 | 2.7 nmols/l (1.2-2.8) |
| Free T4 | 148 nmols/l (50-150) |
| S. PTH | 53 pg/mL |
| 25-OH vit-D | 15 ng/ml (33-100) |
| Total Alkaline Phosphatase | 140 U/L (30- 130) |
D. Interpret the above investigations.
E. Discuss the spectrum of bone disease in a patient with CKD. Do you think the patient’s DEXA abnormalities represent consequences of his kidney disease?
F. Suggest a management plan for this patient.
You must be logged in to post a comment.
he patient has low vit D, normal iPTH and mildly elevated total ALP, normal thyroid function.
– CKD-MBD include those with high turn over patterns: osteitis fibrosa and mixed uremic osteodystrophy and those low turn over pattern as adynamic bone disease and osteomalacia beside osteoporosis
– management plan: replenishment for vit D deficiency by 800-1000 Iu as normal individuals
he patient has low vit D, normal iPTH and mildly elevated total ALP, normal thyroid function.
– CKD-MBD include those with high turn over pattern: osteitis fibrosa and mixed uremic osteodystrophy and those low turn over pattern as adynamic bone disease and osteomalacia beside osteoporosis
– managemnt plan: replenishment for vit D deficiency by 800-1000 Iu as normal individuals
With the TSH normal and sT4 in the normal range, PTH is not exceeding the upper limit 70 (varies cross labs) it seems slightly increased secondary to vitamin d deficiency. for that reason, it seems that the reason for osteopenia is mainly secondary to vitamin d deficiency. We need to supplement the vitamin D, Calcium plus vitamin D may be inappropriate due to calcifications (not overload with calcium)
D – low vitamin D level . thyroid test normal
E – yes
F- replenish vitamin D level
Thank you for the case
Interpret the above investigations
Normal thyroid function
vitamin D deficiency
normal PTH for healthy population
total alkaline phosphatase was slightly elevated mostly due to vitamin d deficiency .
but could rise due to other factors like biluary diseases
if this pt ckd target PTH level not known according to last KDIGO guidelines 2017 but will be individualized according to the case and GFR, as PTH will start to be affected from stage 3A, and so PTH 53 COULD BE LOW ABIT
Spectrum of bone disease in a patient with CKD:
spectrum of bone diseases in ckd could represent one or mixed pathology
Dexa abnormalities shows osteopenia represent mostly vitamin D deficiency rather than complications of his CKD
management
exposure to Ultravoilet rays B better at 10 am in fresh air as polution adsorb the UV rays B
D. Interpret the above investigations.
Normal thyroid profile,
PTH level is not high,
low level of vitamin D
high total alkaline phosphatase level.
E. Discuss the spectrum of bone disease in a patient with CKD. Do you think the patient’s DEXA abnormalities represent consequences of his kidney disease?
The spectrum of bone disease ;
High bone turnover
low bone turnover
mixed type
osteomalacia
osteoporosis
DEXA changes are not related to his CKD , mostly due to Vit D deficiency .
F. Suggest a management plan for this patient.
more work up to confirm cause of CKD
Vit D supplement
Thank you for your fruitful contributions. Here are the model answers by the program’s scientific board.
D: Interpret the above investigations.
Normal thyroid profile, PTH level is not high, low level of vitamin D and high total alkaline phosphatase level.
E: Discuss the spectrum of bone disease in a patient with CKD. Do you think the patient’s DEXA abnormalities represent the consequences of his kidney disease?
Bone disease varied from high Bone turnover, low bone turnover or mixed uremic osteodystrophy. Moreover, osteopenia and osteoporosis could be related to kidney disease. In the setting of CKD, circulating 25(OH)D levels begin to decrease from the earliest stages due to numerous factors, including skin hyperpigmentation, reduced skin synthesis of cholecalciferol, dietary restriction, impaired intestinal absorption, increased vitamin D catabolism, and important urinary losses of DBP and vitamin D metabolites in the case of severe proteinuria. CKD is also characterized by the status of vitamin D hypo-responsiveness because of a progressive loss of VDR in the parathyroid cells. so, the patient’s DEXA abnormalities might be caused by his kidney disease and vitamin D deficiency (2), (3).
F: Suggest a management plan for this patient.
Patients with an estimated glomerular filtration rate (eGFR) >30 mL/min who have no biochemical evidence for chronic kidney disease-metabolic bone disorder (CKD-MBD) (eg, hyperparathyroidism, hyperphosphatemia) should have similar vitamin D supplementation as patients with normal renal function. For individuals with serum levels of 25-OH vitamin D 12-20 ng/ml, initial supplementation with 800 to 1000 international units daily may be sufficient. A repeated serum 25-OH vitamin D should be obtained three months of therapy to assure obtaining the goal serum 25(OH)D level. If the goal level is not achieved, higher doses may be necessary (4).
References:
2. Waziri B, Duarte R, Naicker S. Chronic kidney disease–mineral and bone disorder (CKD-MBD): current perspectives. International journal of nephrology and renovascular disease. 2019;12:263.
3. Ureña Torres PA, Souberbielle JC, Solal MC. Bone Fragility in Chronic Kidney Disease Stage 3 to 5: The Use of Vitamin D Supplementation. Metabolites. 2022;12(3):266.
4. Cohen A, Drake MT. Clinical manifestations, diagnosis, and treatment of osteomalacia. Dostupnona:https://wwwuptodate.com/contents/clinicalmanifestations-diagnosis-and-treatment-of-osteomalacia [pristupljeno: 1606 2020].
Normal TFT
Appropriate PTH for his stage IIIa CKD (35-70 pg/ml as per KDOQI).
Slightly increase ALP
Spectrum of bone disease in CKD:
1. Osteitis fibrosa(high bone turnover): high PTH.
2. Osteomalacia: defective mineralisation
3. ABD
4. Osteoporosis/ osteopenia
5. Mixed
DEXA keeping with Osteopenia as a result of significant low vitamin D as a consequence of his CKD:
1. limits the delivery of 25-hydroxyvitamin D to the site of the 1α-hydroxylase in the proximal tubule.
2. Phosphate retention either directly or by inducing an increase in FGF-23 also decreases the activity of 1α-hydroxylase.
3. circulating PTH fragments may directly decrease calcitriol production.
4. Loss of Vit D binding protein in a setting of severe proteinuria.
5. decrease VDR in parathyroid gland
Managment:
Vit D loading follow with a maintainance
D-normal thyroid and parathyroid level, low v.d and slight increase of alkaline phosphatase
E-No DEXA abnormality is not related to CKD most probably related to V.D deficiency
F-50000 U V.D 25 once per week for 3 m till level of V. D more than 30 then give maintenance .
thyroid function is with in normal range.
vitamin D deficiency
parathyroid is normal.
Total Alkaline Phosphatase slightly elevated
patients Dexa examination may not relate to the CKD rather is vitamin d deficiency.
suggestion should take vitamin D 1000iu/day and check vitamin d again
D. Interpret the above investigations.
Thyroid function tests were normal, there was a vitamin D deficiency, PTH was normal =53 (15-75) and Total alkaline phosphatase was slightly increased above normal (due to vitamin d deficiency ).
E. Discuss the spectrum of bone disease in a patient with CKD. Do you think the patient’s DEXA abnormalities represent consequences of his kidney disease?
The patient has Mixed uremic osteodystrophy, low turnover bone disease (osteoporosis) and low vitamin D (osteomalacia), as well as high alkaline phosphotase.
DEXA results most likely due to kidney disease and vitamin D insufficiency.
F. Suggest a management plan for this patient.
An initial supplementation of 800 to 1000 international units per day may be adequate. A repeat blood 25-OH vitamin D level should be acquired after three months of therapy to ensure achievement of the target serum 25(OH)D level. If the target level is not reached, larger doses may be required. stop calcium supplement
Normal thyroid function tests,vitamin D deficiency, normal PTH and total alkaline phosphatase was slightly elevated above normal (due to vitamin d deficiency ).
If serum of the patient is 1.9 (eGFR 47ml/min) stage IIIa with vitamin D deficiency, expected PTH is slightly higher than 53
Spectrum of bone disease in a patient with CKD:
A systemic disorder of mineral and bone metabolism due to CKD manifested by either one or a combination of the following:
Dexa abnormalities (osteopenia) represent vitamin D deficiency not consequences of his kidney disease
Interpret the investigations:
normal thyroid function.normal PTH, high total alk. phosphatase and severe deficiency of 25-OH vit-D osteomalacia secondary to low vitamin-D.
——
DEXA result not attributed to CKD
most likely 2ry to vit d deficiency
For vit d replacement
Normal tyroid fun test
With low turnover as adynmic bone dis
with non sepsific alkalain phos incrase could be due another pathology ( malabsorption or agrrisseve treat ckd mbd ln past
i will stop all calcium to enhance parathyroid
replase vid d
to repate bone profile and PTH and consider PTH replacment if not imorove within 3 month and dexa if no done since 2 years ago
D- normal thyroid profile, normal PTH with vit D defiency and elevated Alk phosphatase
E- spectrum of bone disease in CKD patients :
1- high turnover bone disease (osteitis fibrosa cystica )
2- low turnover bone disease ( adynamic bone disease and osteomalacia)
kidney disease is not related to these abnormalities as with elevated alk phos. , it is expected to have high turnover proved with elevated PTH levels which is not found in this patient so it is not the classic picture of CKD MBD
F- management should include IV vit D doses and correct any prerenal cause of AKI and periodically follow up S.Cr and Abd US and urine analysis
Thank you dr Mark.
what is the target PTH level in this stage of CKD according to KDIGO guidlines?
the patient has normal thyroid funtion and pth is adequte for for ckd stage3.
DEXA result not attributed to CKD most likely 2ry to vit d deficiency
ttt:- 25 hydroxy vit d replacement
Thanks dr Ahmed.
Here are some explanation for this case:
This patient has a normal thyroid profile along with a picture of adynamic bone disease demonstrated by low PTH and low Vit D levels and in the same time high ALP .this finding is present in osteomalacia due to primarily reduced levels of vit d .
E. Discuss the spectrum of bone disease in a patient with CKD. Do you think the patient’s DEXA abnormalities represent the consequences of his kidney disease?
This finding could be related to This patient’s CKD, especially as Vit D is affected by CKD with absorption from the intestine and loss of VDR expression in severe proteinuria and this may be directly related to his ckd stages
F. Suggest a management plan for this patient.
This patient need to confirm the diagnosis of APKD by doing genetic and MRI tresting
encourage oral rehydration
Excellent dr Rihab.
what about the management plan of this patient bone abnormality do you recommend?
D* normal thyroid function, normal or low PTH, low vitamin D and increase total alkaline phosphotase.
E* The patient has low turnover bone disease (osteoporosis) and low vitamin D (osteomalacia) , alkaline phosphotase elevated but this total not bone specific.
Also patient has flecks of calcification in the kidneys maybe due to hypercalciurea (in ADPKD nephrocalcinosis mostly due to increase uric acid crystals but hypercalciurea less commonly occurs), also the patient is athletic and may use calcium supplements
F* treatment of vitamin D deficiency
, stop calcium supplement if used
Encourage drinking water, encourage exercise
Great dr Israa.
what is the target PTH level in this stage of CKD?
35-70
Interpret the above investigations.
TFT are normal
PTH low to normal
Vitamin D deficiency
High ALP / low bone turnover and osteomalacia
Discuss the spectrum of bone disease in a patient with CKD. Do you think the patient’s DEXA abnormalities represent consequences of his kidney disease?
The spectrum include:
. High bone turnover
.low bone turnover
.mixed type
.osteomalacia
.osteoporosis
Yes the DEXA changes are related to his CKD
This case mostly adynamic bone disease with osteomalacia and mixed type CKD-MBD.
Suggest a management plan for this patient.
Management plan include :
Treatment of a dynamic bone disease by stopping calcium supplement,
Give vitamin D supplement
Stop active vitamin D if any
Monitor serum ca , p, PTH , vit D , every 3-6 months .
Regarding his disease :
Good hydration
Low ph diet
Low salt
Avoid protein
Good control of BP
Control infection
Avoid stone formation
Treatment of anemia
We can use osteoanabolic drugs with close follow up to calcium
Tolvaptan can be use
We can use daprodustat to treat anemia and also to control cyst size in ADPKD patients.
Thank you very much dr Asmaa.
If you could please explain why you consider this case as adynamic bone disease?
D:
The above lab reveiled sever vit d deficiency.
Subclinical hyperthyroidism
high normal ALP.
Hypoparathyroidism.
E:
ABD, low turn over bone disease, with osteopenia.
F:
Give Vit D supplement.
Stop calcium supplement
Stop active vit D if already given
Thanks dr Kamal.
This patient has normal thyroid profile, so why you consider him to have subclinical hyperthyroidism?
Interpret the above investigations:
Normal TFT, PTH, with low 25 vit D, and slightly elevated TALP
Discuss the spectrum of bone disease is a patient with CKD. Do you think the patient’s DXA abnormalities represent consequences of his kidney disease?
There are 3 main types of CKD-MBD
Looking at patient’s labs, DXA scan results, and knowing that he is young athlete, functional hypothalamic hypogonadism could be the reason for his low bone turnover.
Suggest a management plan:
Excellent dr Asma. I appreciate your response.
1- normal thyroid function test and PTH with vitamin D deficiency and high ALK
2- high or low bone turnover
mixed disease
osteoporosis
it can be and can’t be due to CKD sine AlAklabi be phosphates is not bone specific
3- rule out liver disease
ca and phosphate level
vitamin D replacement
cr and eGFr
bone specific ALK
thanks dr Areij.
answer – D
Vit- D deficiency ,high ALP ,normal PTH, normal thyroid function .
answer E
mixed bone disease .
high turnover bone disease.
low turnover bone disease.
osteoporosis.
osteomalacia.
The DEXA changes attributed to the CKD-MBD
answer F
try to slow progression of the disease by
good control of blood pressure.
medical counselling.
avoid nephrotoxin medication .
urine analysis.
abd u/s annual.
measure s.ca ,p ,every 3-6 months, PTH every 12 months.
vit- D supplementation.
vasopressin receptor antagonists.
Great dr Ashraf.
D.Vitamin D deficiency , high AP indicate that bone have increased osteoclast activity.
E ..high turnover bone disease
Low turnover bone disease osteomalacia osteoporosis, mixed bone disease
F. Regular control of Vit D and phosphat level every 3to 6 mo and regular control of iPTH every 6-12 mo.
Low phosphate diet,
Vit D supplementation
Thanks dr Nour.
Answer D:
Normal TFT
Significant Vitamin D deficiency
Total ALP – slightly elevated
Answer E:
Types of bone disease:
The DEXA changes could be attributed to the CKD-MBD
Answer F:
Regular follow-up according to KDOQI guidelines, regarding to SHPT management
Preserve renal function, and avoid nephrotoxins
Regular exercise
Vitamin D supplementation
Evaluate renal sizes, including an MRI for kidney volumes
Dialysate 1.25
I appreciate your answer dr Riaan.
Your management plan is directed toward patients on hemodialysis, but this patient has CKD stage III a.
D.Normal thyroid, normal parathyroid level, low vitamin D, and High ALP consistent with high bone turnover
E. adynamic bone disease, osteomalacia, and mixed disease, yes is the consequence of his disease
F. Management Plan: Phosphate diet restriction, give Vit D analog, follow up for calcium, phosphate, vitamin D and PTH.
Thank you dr Mohammed.
D- The above investigations was 2 years back, with normal thyroid. His alkaline phosphatase was high, so probably was having High bone turnover despite “normal” PTH for his kidney function (May be stage II 2 years back), He has deficiency of vit D which may be a big contributor to his bone disease.
E-
–High-turnover bone disease
-Adynamic bone disease
-mixed bone disease
-Osteomalacia
-Osteoporosis
Yes, his DEXA could be secondary to his kidney disease, it’s known that CKD-MBD starts @ stage II CKD
F-
We have to ascertain which disease does this gentleman have in order to treat well
He certainly needs Vit D replacement, as this will suppress the parathyroids, he would need PO4 restriction in diet (less need for phosphaturic hormones)
then he would need follow-up of CKD-MBD parameters
We also need to retard the progression of the disease by controlling BP.
May need Tolvaptan
Thank you dr Hassan.
D- interpretation of investigation
Hypovitaminosis D,slight elevation of total alkaline phosphatase other was normal value.
E-the spectrum of bone disease in patient with ckd high bone turn over ,low bone turn over ,mixed oesteoprosis and oesteomalicia. Yes I think the dexa scan abnormality related to underlying kidney diseases
D- ttt plane of these patient will be give patient active vit d avoid any nephritoxic madications close monitoring of kidney function regular check for ca po4 pth vit d level for every 3 to 6 months
Good dr Rabab.
D. Interpret the above investigations.
normal thyroid function.
normal PTH, high total alk. phosphatase and severe deficiency of 25-OH vit-D is going with osteomalacia secondary to low vitamin-D.
E. Discuss the spectrum of bone disease in a patient with CKD. Do you think the patient’s DEXA abnormalities represent the consequences of his kidney disease?
-High-turnover bone disease
-Adynamic bone disease
-mixed(high and low turnover )
-Osteomalacia
-Osteoporosis
The severity of low vitamin D does not match the degree of CKD. maybe he has underlying other causes for low vit-D.
F. Suggest a management plan for this patient.
I will start the replacement of Vit-D by giving Ergcalcferol 50000 IU weekly for 4 weeks and then monthly for 5 months
repeat for serum calcium and phosphate, every 6–12 months; and for PTH, based on baseline level and CKD progression.
If proven the case is ADPKD, MRI is to check the volume TKV and check the Mayo classification.
urine analysis, If proteinuria, start ACEi
Good hydration > 3 lier per day
avoid any nephrotoxic medication
Excellent dr Weam.
1- the investigation revealed normal thyroid function
hypo vit.d
Hight turn over bone disease
management plan and recommendation
evaluate bp if Hight >>>>control
control risk factor as dm ,bp
control any source of infection >>>>pt. risk of uti
f/u renal imaging as risk of stone formation
avoid nephrotoxic medication especially NSAI
alfacalcidol 0.25
f/u ca . pi, alp . 25vitd pth every 3-6 month
Thank you dr Elsayed.
Patient with normal thyroied function , normal parathyroied but very low vit d level this is mostlikly cause of his bone disease so need for vit D treatment , beside nephrology folow up for his kidney status , diet control , avoid for any nephrotoxiic medication
Thanks dr Abdulrahman.
D–1-normal thyroid function
2-severe vitamin D deficiency
3-low PTH
E- spectrum of bone disease in apatient with CKD
low bone turnover (ADBD ,osteomalacia)
high bone turnover (osteitis fibrosa cystica)
yes it can represent consequences of his kidney disease
f- 1- correct hypvitaminosis D by giving ergocalciferol 300 000 iu (50000 iu /week for 6 week )
2-fu calcium and po4 level /2 weeks
3-review medication (if the patient recieving VDRA or calcium or cinacalcet )
4-use dialysate ca 1.25 mmol/l
Great dr Emad.
A.Interpret the above investigations.
B.Discuss the spectrum of bone disease in a patient with CKD. Do you think the patient’s DEXA abnormalities represent consequences of his kidney disease?
–Generally we follow TMV classification but we see these following abnormalities:
–Yes, Dexa abnormalities may be due to CKD but one would treat adynamic bone disease before treatment of osteoporosis
C.Management plan: This is multi-displinary
Thanks dr Ben. I would like to illustrate some points:
Thanks prof
D. Interpret the above investigations.
E. Discuss the spectrum of bone disease in a patient with CKD. Do you think the patient’s DEXA abnormalities represent the consequences of his kidney disease?
1- High bone turnover: renal osteodystrophy.
2- Low bone turnover: adynamic bone disease and osteomalacia.
F. Suggest a management plan for this patient.
1- control of BP.
2- body weight control.
3- avoid nephrotoxics, including bodybuilders as anabolics.
4- follow up of renal chemistry, calcium, and phosphorus every 3 months.
5- follow up of PTH every 6 months.
Thank you dr Ibrahim.
For individuals with serum levels of 25-OH vitamin D 12-20 ng/ml, initial supplementation with 800 to 1000 international units daily may be sufficient. A repeated serum 25-OH vitamin D should be obtained three months of therapy to assure obtaining the goal serum 25(OH)D level.