W1S2:

Three months later after diet control and doubling of phosphate binders and use of calcium supplements, the patient presented with the following laboratory investigations

Test

Value

S. Creatinine

4.2 mg/dL

S. corrected Calcium

8.6 mg/dL

S. Phosphorus

5.9 mg/dL

iPTH

481 pg/mL

D. Interpret the current laboratory investigations.

E. Suggest your management plan based on the current presentation.

35 Comments

  • Radwa Ellisy


    The calcium level raised and the phosphorus lowered with the management plan. However the iPTH raised.

    • Adding cinacalcet 30 mg daily for controlling iPTH with follow up pf iPTH after 1 month
  • Radwa Ellisy


    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

  • Radwa Ellisy


    The calcium level raised and the phosphorus lowered with the management plan. However the iPTH raised.
    – Adding cinacalcet 30 mg daily for controlling iPTH with follow up pf iPTH after 1 month

  • Mahmud ISLAM


    Knowing the P-lowering drug and dose will guide me. Despite the applied measures along with this LAB, I will prefer non-Ca containing phosphorus lowering agent as long as it is eligible alone. I expect an elevation of calcium further especially as I need to add calcitriol (low dose; will titer later). I will check Ca/P/PTH 1 month later and modify my treatment.

  • Muhammad Soobadar


    D secondary hyperparathyroidism
    E cinacalcet

  • Rola Kotob


    Interpret the current laboratory investigations.
    phosphate decreasing towards the norml level but still high
    Ca is better normal now
    PTH INCREASED
    Suggest your management plan based on the current presentation.
    need parathyroid scan assessment
    phosphorus better but still high so better wait for vit D analogues and continue on same phosphte binders
    as corrected Ca accepted we can start calcimimetic if no contraindications and patient ca afford its GIT troubles
    frequant follow of the parameters

  • Ahmed Altalawy


    calcium improved , partial improvement in P , PTH increased but still in target
    CA P product now acceptable so we can increase calcium as a P binder
    continue in diet control of P
    for PTH we can start small dose cinacalcet with follow up of calcium
    postpone use of alpfacalcidol till better control of P .

  • Mahmoud Sobh


    Thank you for your fruitful contributions. Here are the model answers by the program’s scientific board.

    D       Interpret the current laboratory investigations.

    Serum calcium started to rise after using calcium containing phosphate binders. Serum phosphorus is trending in the right direction. PTH level increased despite partial improvement in both calcium and phosphorus levels.

    E.       Suggest your management plan based on the current presentation.

    Phosphate binders should be continued. Cinacalcet might be considered especially if total or bone specific alkaline phosphatase are at  the higher levels. Adding alfacalcidol later on might be an option as the Cinacalcet is expected to lower down the phosphorus level toward the normal level. 

  • Amna Kununa


    Ca and Phosphate within reasonable level

    PTH within target range but raising

    As per KDIGO

    Suggest

    1. lowering elevated phosphate levels toward the normal range.

    2. maintaining serum calcium in the age-appropriate normal range

    3. maintaining iPTH levels in the range of approximately 2 to 9 times the upper normal limit for the assay

    4. If there is marked changes in PTH levels in either direction within this range prompt an initiation or change in therapy to avoid progression to levels outside of this range.

    So I will continue on previous plan, I may consider adding small dose of calcimimetics, and keep eye on s.Ca

    Continue monitoring

  • Hagar Ali


    D- ca corrected and phosphorus improved but still high ,pth still normal but increased
    E- use calcitriol to control pth and continue previous diet and binder regimen but if s.ph begin to increase so we need to shift to calcimimatics and monitor s.ca to avoid hypocalcemia.

  • Ahmed Wagih


    the calcium is corrected, but serum phosphorus and PTH worsen. i suggest addition of calcimimetics to control PTH, increase non calcium based phosphate binder to maximum

  • Mohamed Abdulahi Hassan


    creatinine is still elevated … and PTH higher than previous result.
    phosphorus slightly elevated ..
    continue same medication and follow up

  • Rania Mahmoud


    D.Interpret the current laboratory investigations.
    In comparison to the old lab, the new lab shows some improvement: normal serum calcium, slightly elevated serum phosphorus, and PTH that is still within the acceptable range but higher than the previous result. Serum creatinine is lower than before, which could be due to dietary control or improved dialysis adequacy.
    E. Suggest your management plan based on the current presentation.
    Continues on the same treatment
    follow up serum ca calcium and phosphate every month ; and for PTH, every 3 months
    – dietary phosphate restriction
    – Calcitriol or vitamin D analogue and follow the levels of Ca, P, and PTH. 
    If PTH still increases, cinacalcet is recommended 

  • Alaa Abdel Nasser


    New lab shows some improvement in comparison to previous lab
    normal serum calcium, slightly elevated serum phosphorus and PTH still in the accepted range but elevated than previous value
    regarding serum creatinine it decreased than previous, it may be due to dietary restriction or improvement of dialysis adquecy

    1- continue on dietary phosphate restriction
    2- reduce dose of calcium containing phosphate binder (keep the lowest possible dose to maintain calcium level within normal)
    3-add non calcium containing phosphate binders
    4-follow up serum ca calcium and phosphate, every month ; and for PTH, every 3 months

  • Mahmoud Elsheikh


    Controlled hyperphosphatemia.
    active vit D 
    monthly monitor PTH level to avoid ABD.
    —-
    review medication.
    Discuss Patient compliance.
    Add active vit D small dose.

  • Khaldon Rashed Ahmed Moqbil


    Control PTh on target with stage ckd
    phos still high

    diet control
    low dose vid d analogs
    non ca phos binder
    preper for RRT
    PTH every 3 months and RFTca phos monthly

  • Mark Nagy Zaki Amin Mark


    D- improved values of s.cr , ca , po4 as compared to previous labs and average PTH levels for a HD patient
    E- continuing on the same plan would be enough for now as lab results are improving

  • Rihab Elidrisi


    D. Interpret the current laboratory investigations.
    The level of Pi dropped but was still higher than the recommended dose. Ca within the recommended dose.
    The level of PTH increased.

    E. Suggest your management plan based on the current presentation.
    Suppression of PTH via calcitriol and other vitamin D analogues has been the therapeutic mainstay for the treatment of secondary hyperparathyroidism (SHPT).
    So I will start calcitriol or Vitamin D analogue and follow the levels of Ca, Pi, and PTH. 
    If PTH progressively increases, I will add cinacalcet.

  • Israa Hammoodi


    D* better s. Calcium, decrease s. Phosphorous (although slightly above target) but elevated iPTH so need to check vitamin D level and bone specific alkaline phosphotase
    E* continues on the same treatment but treat vitamin D deficiency if present and monitor iPTH.

  • Asmaa Salih KHUDHUR


    After three months of our treatment, there is improvement in calcium level, slight reduction of creatinine , slightly reduction of ph but it’s still at the upper side , SHPT worsening.
    my management plan will be to continue on the previous strategy with adding cinacalcet .

  • KAMAL ELGORASHI


    D:
    Controlled hyperphosphatemia.
    SHPT, need to add active vit D with monthly monitor PTH level to avoid ABD.
    E:
    Keep ongoing medication.
    Add active vit D small dose with monitoring
    Balanced Ca supplement to avoid calcium load .
    

  • Asma Aljaberi


    Interpret current labs investigations.
    ESRD with low normal Ca corr, improving but still high Ph, and worsening iPTH.

    Suggest your management plan based on the current presentations.

    • Make sure cholecalciferol part of his medications. Then add vit D analogues. Will add paricalcitol IV during dialysis sessions.
    • Will hold off on cinacalcet. It might decreases Ca further. I rather not starting it at this point of time.
  • Areij Alotaibi


    1- low Calcium, high Phosphate and
    Secondary Hyperparathyroidism.

    2- encourage Patient compliance

    3-needs caSR agonist either orally or IV with monitoring of calcium level

  • Ashraf Ahmed Mahmoud


    Answer D:

    Low Calcium, high Phosphate and elevated PTH –
    Secondary Hyperparathyroidism.

    Answer E:

    -Discuss Patient compliance for medication.
    -review his medication and stop high phosphate medication ( esp. enema).
    -Improve dialysis adequacy.
    -Etecalcitide.

  • Nour Al Natout


    D. Normal corrected calcium but level of phosphorus still high what cause further increase in PTH level.

    E. Discuss Patient compliance to phosphate binders and low phosphat diet – then increase dosage of phosphate binders and if maximal increased then Start mimpara

  • Riaan Flooks


    Answer D:

    • Low Calcium, high Phos and elevated PTH – suggestive of Secondary Hyperparathyroidism

    Answer E:

    • Regular follow-up on bloods as per protocol
    • Improve dialysis adequacy if not according to standards
    • Cinacalcet
  • MOHAMMED HAJI HASSAN


    D. Serum Phosphate and parathyroid still is high most like is secondary hyperparathyroidism
    E. add cinacalcet to the previous treatment plan, follow up serum calcium, phosphate, vitamin D and iPTH.

  • HASSAN ALYAMMAHI


    D-Despite the measures to control PO4 and PTH, they still went up, which means patient is now having SHPT (Most likely)

    E-Adding (increasing) Vitamin D may cause further absorption of PO4 from GUT and exacerbate the problem, so I’ll add Cinacalcit (or Etelcalcitide), will observe iPTH monthly.
    if no response on maximizing Calcimemetics the patient may need Parathyroidectomy

  • Rabab ALaa Eldin keshk Rabab


    D- interpretation of investigation more elevation of pth still hyperphosphatemia normal ca level so still in state of secondary hyperparathyroidism.
    E-management continue phosphorus chelator and diet restrictions
    Add calcimimitic drugs adquate dialysis
    Close monitoring to serum ca po4 pth

  • Weam El Nazer


    D. Interpret the current laboratory investigations.

    The level of Pi dropped but was still higher than the recommended dose. Ca within the recommended dose. The level of PTH increased

    E. Suggest your management plan based on the current presentation.

    Suppression of PTH via calcitriol and other vitamin D analogs has been the therapeutic mainstay for the treatment of secondary hyperparathyroidism (SHPT).
    So I will start calcitriol or Vitamin D analogue and follow the levels of Ca, Pi, and PTH.
    If PTH progressively increases, I will add cinacalcet.

  • Elsayed Ghorab


    lab. investigation revealed
    normal calcuim
    still hyperphosphatemia
    SHPT
    start cinacalcet

  • Abdulrahman Almutawakel


    There is improvement in his ca , p but increased PTH , may he needs for Cinacalcet to be added also vit d

  • Emad mohamed mokbel Salem


    D- 1-calcium and iPTH within target according to KDIGO guideline but we need to close fu of PTH as rising titer and after control of s phosphorous we can add VDRA
    2-high serum phosphorous

    E- dietary phosphate restriction (avoid inorganic phosphate diet ) and diet referal
    adequate HD by increase time or frequency or home HD
    -FU PTH as rising level and we can add VDRA when po4 in normal level

  • Ben Lomatayo


    -Interpret the current laboratory investigations.

    • Ca within low normal, pi is still high, and high iPTH indicating SHPT
    • iPTH 2 to 9 folds is optimal for HD patient but unknown in CKD (KDIGO 2017)
    • High SCr

    -Suggest your management plan based on the current presentation.

    • Dietary review again make sure that; the protein phosphorous ratio 12/1000 g
    • Avoid drinking Meat soup
    • Encourage plant phosphate ; low bio-availability around 30%to 50% compared to animal proteins 60% to 100%
    • Avoid processed or canned foot
    • Review medications; some drugs may be the source of phosphate e.g amlodipine, ACE-i, antidepressants
    • Extended or nocturnal HD
    • Consider kidney transplantation
  • Ibrahim Omar


    D. Interpret the current laboratory investigations.

    • serum calcium was decreased but it is still high.
    • serum calcium and PTH are both within targets.

    E. Suggest your management plan based on the current presentation.

    • ensure that the patient has adequate hemodialysis, not less than 12 hours weekly.
    • continue a low phosphate diet, including low fish, milk products, animal proteins, processed food, beverages, …etc.
    • continue the same dose of phosphate binders, mainly sevelamer or lanthanum.
    • extra sessions or daily nocturnal hemodialysis may be needed to control severe hyperphosphatemia.
    • if the itching was not improved after normalizing serum phosphate, the following can be added :

    1- oral antihistaminics as Cetirizine.
    2- Neuroleptics such as Gabapentin or pregabalin.

    • 3- phototherapy as PUVA

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