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
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
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
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.
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
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 .
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.
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
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.
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
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
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
Controlled hyperphosphatemia.
active vit D
monthly monitor PTH level to avoid ABD.
—-
review medication.
Discuss Patient compliance.
Add active vit D small dose.
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
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.
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.
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 .
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 .
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.
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
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.
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
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
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.
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
The calcium level raised and the phosphorus lowered with the management plan. However the iPTH raised.
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
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
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.
D secondary hyperparathyroidism
E cinacalcet
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
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 .
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.
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
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.
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
creatinine is still elevated … and PTH higher than previous result.
phosphorus slightly elevated ..
continue same medication and follow up
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
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
Controlled hyperphosphatemia.
active vit D
monthly monitor PTH level to avoid ABD.
—-
review medication.
Discuss Patient compliance.
Add active vit D small dose.
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
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
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.
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.
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 .
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 .
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.
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
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.
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
Answer D:
Answer E:
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.
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
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
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.
lab. investigation revealed
normal calcuim
still hyperphosphatemia
SHPT
start cinacalcet
There is improvement in his ca , p but increased PTH , may he needs for Cinacalcet to be added also vit d
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
-Interpret the current laboratory investigations.
-Suggest your management plan based on the current presentation.
D. Interpret the current laboratory investigations.
E. Suggest your management plan based on the current presentation.
1- oral antihistaminics as Cetirizine.
2- Neuroleptics such as Gabapentin or pregabalin.