A 50-years-old male patient, HTN for 10 years, ESKD on hemodialysis for 6 years, presented with generalized itching for 3 months.
Routine review of the patient’s Laboratory investigation revealed:
|
Test |
Value |
|
S. Creatinine |
5.1 mg/dL |
|
S. corrected Calcium |
7.9 mg/dL |
|
S. Phosphorus |
8.2 mg/dL |
|
iPTH |
338 pg/mL |
A. Interpret the previous laboratory investigations.
B. Give a management plan for this case.
C. What other investigations do you recommend?
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the patient has hyperphosphatemia and hypocalcemia and hyperparathyroidism (within the limit according to KDIGO guidelines)
the itching may be due to hyperphosphatemia
b- management plan:
for hyperphosphatemia: binders calcium-based or non-calcium-based as sevelamer
c- other investigation:
vit D level and ALP and DEXA scan
For this patient with 5D stage along with uremia high phosphorus seems to have a major role in pruritus. It is good if I prescribe a potent phosphorus-lowering agent like Lantanium or sevelamer. after lowering phosphorus toward normal (<5.5) I may shift to low dose CA acetate plus low dose sevelamer (PTH is appropriate) I may start low dse calcitriol if PTH is progressing later.
But in practice and in compliance with insurance policies (I will tray to lower the P level with diet+HD+ Aluminium-containing drug (we use antepsin: sucralfate) for shot period, check P then shift to calcium-containing drug. (we can prescribe sevelamer or lanthanum not before 3 months, after Hd with KT/V>1.4 etc.)
ckd with secondary hyperparathyroidism
B dietary modification to reduced phoshpate
calcium /non calcium binders
can consider cinacalcet later on
C vitamin D ,ALP
thank you for the case
50y old ESRF on HD with Itching HIGH P, apparently hypocalcemic, PTH within target range according to last KDIGO guidlines 2017
first need full medical history of all other comorbiditeis as DM , anemia ect
Drug history is he on treatment (dose duration , and timing in relation to dialysis)
(this high phosphate although pt on treatment like sevelamer or not, and is he taking any vit D analogues) before any management need clear history and drug history, dialysis prescription history
management
As Phosphte high so most probably its the cause of itching or ureamia , but should search for other possible causes if itching didnt get better by correcting previous parameters
-review diat regimen, drug history
-strict low phosphate diet
-review dialysis adequacy not just kt/v, check duration, flow, filer surface area , all clinical and lab parameters need to be assessed
-increase dialysis duration first extend dialysis u can use SLED or Nocturnal dialysis
-adding drugs will depend on hes previous medication for example
add sevelamer or increase its dose if not available add ca containing phophate binder
dont add vit D analogues till you correct phophate, especially PTH within acceptable range
dont add calcimimetics till you correct Ca
for symptomatic treatment of Uremic pruritus not always related to phosphate but whats common is common and whats abnormal should be corrected first
exclude dermatological causes
beside previous measures cold shower, creams, anti-histamines, opioids and gaptin could be used some time systemic steroids
investigation needed
frequant measures of dialysis adequacy kt/v
be sure of frequant water treatment check
renal profile , CBC , iron profile
vit D level, Dexa scan bone specific alkaline phosphatase
parathyroid scan
Echo
ESRD on regular HD , Hypocalcemia , Hyperphosphatemia , PTH in target .
itching mostly due to Hyperphosphatemia
we need to check if patient receiving prescribed HD dose or not
Also check for efficiency of HD access
counselling about compliance to diet and phosphate binder
for Hypocalcemia if patient on cinacalcet decrease dose , I don’t prefer use of high calcium dialysate in this situation with high CA P product .
for Hyperphosphatemia , diet control , avoid use of Alphacalcidol ,better to avoid calcium containing P binder with this high CA P product , we can use HDF .
I will recommend to do
kt/v
bone specific alkaline phosphtase .
Thank you for your fruitful contributions. Here are the model answers by the program’s scientific board.
A. Interpret the previous laboratory investigations.
According to the previous laboratory data, the patient has mild hypocalcemia, hyperphosphatemia, PTH level is within target range according to KDIGO 2017 recommendations for CKD MBD (2-9 folds of upper normal limit). Hyperphosphatemia mostly is the cause of itching.
B. Give a management plan for this case.
The management should be targeted toward lowering serum phosphate level through:
C. What other investigations do you recommend?
Total and bone specific alkaline phosphatase is recommended to determine the type of renal osteodystrophy. 25 (OH) vitamin D level should be assessed.
A-ESRD on dialysis with hyperphosphatemia and hypocalcemia ,normal pth
B- efficient dialysis kt/v to be more than 1.2
at least 4h session 3 time lw.
low phosphate diet.
use phosphate binder prefer to use ca base binder.
stop one alpha
we can use high ca dialysate to correct s.ca.
use antihistaminic and emollient for his itching .
C- kt lv
v.d25
ALP
S. Mg
ESKD on HD complicated with SHPT with hypocalcemia and hyperphosphatemia and acceptable PTH (two to nine times the upper limit for the PTH assay).
Presented with generalized itching, most common risk factors:
Inadequate dialysis
Hyperparathyroidism
Elevated calcium x phosphorus product
Xerosis (secondary to sweat gland atrophy)
Elevated serum magnesium and aluminum concentrations
Anemia
Initial therapy:
Optimal dialysis since underdialysis is commonly associated with pruritus
Optimal treatment of hyperparathyroidism, hyperphosphatemia, and hyperMg
Regular use of emollients
Management of hyper P:
A target phosphate goal 3.5 and 5.5 mg/dL (1.13 and 1.78 mmol/L)
Phosphate restriction: moderate restriction of phosphate intake in dialysis patients, without compromising nutritional status.
Inadequate dialysis and achieving recommended Kt/V target
Phosphate binders
Prefer calcium base binder here, which help in calcium correction
Kidney transplantation is definitive therapy for uremic pruritus
investigations:
BsALP
vit D
s.Mg
Check for vascular calcification: lateral abdominal radiograph and echo
ckd stage 5 …
creatinine . iPTH and Phosphorus are elevated.
secondary hyperparathyroidism,
Sevelamer 800mg tablet
rocaltrol tablet
dermatology consultation
albumin
parathyroid ultrasound and Bone biopsy
A. Interpret the previous laboratory investigations.
A case of HTN and ESRD on HD presented with pruritus
Regarding lab:: mild hypocalcemia,, hyperphosphatemia and accepted serum PTH.
It is most likely due to hyperphosphatemia,, hyperparathyroidism and ureic toxins
B. Give a management plan for this case.
– Diatery phosphate restriction depend on dietitian review
add renagel 800 mg tablet
– Frequent HD sessions and increase duration
– Exclude other causes of itching e.g: dermatological cause or hypersenstitvity reaction
– Antihistamin for itching + Skin moisture
– Ca dialysate may be needed
– Calcimimatic drugs
– Usage of calcium supplements.
– Cholecalciferol to help in increasing Ca, decreasing PTH.
C. What other investigations do you recommend?
1. URR
2. Kt/V.
3. follow up s.cr, urea (pre, post) and po4
4. S. Vit D level.
5. Serum albumin
6. DXA.
7. Echocardiogrophy.
A case of HTN and ESKD on CHD presented with pruritus
Regarding lab:mild hypocalcemia,hyperphosphatemia and accepted serum PTH.
It is most likely due to hyperphosphatemia,hyperparathyroidism and ureic toxins.
1-Diatery phosphate restriction, add calcium containing phosphate binders
2-Asses dialysis adquecy by measuring kt/v (if HD is not sufficient, increase hemodialysis dose with extended sessions or more frequent sessions)
3-Exclude non uremic causes of itching;dermatological causes,drug induced hypersensitivity and allergies(to filters or circuit components)
4-Exclude systemic causes like Cholestasis, Viral hepatitis, Primary biliary cirrhosis Hematologic malignancy, Hodgkin’s lymphoma, Cutaneous T-cell lymphoma Polycythemia vera, Post-herpetic neuralgia andHuman immunodeficiency virus
5- For CKD-aP ,treatment options for uremic pruritus include many topical and systemic therapies such as topical capsaicin cream, emollients, tacrolimus cream, ergocalciferol, gamma-linolenic acid (GLA), gabapentin, anti histaminic,μ-opioid receptor antagonist, κ-agonist, and ultraviolet B (UVB).
CKD-MBD: Hypocalcemia,symptomatic Hyperphosphatemia and SHPT.
———-
——————-
Further investigation:
A- renal impairment with hypocalcemia , hyperphosphatemia and normal PTH value as regard ptn on HD .
B- 1-calcium containing phosphate binders to replete calcium and decrease po4 levels
2- dietary restriction depending on the phosphate pyramid algorithm
3- local soothing agents for symptomatic itching
4- inceased Ca dialysate may be needed
5- daily noturnal HD for better removal of PO4
C- 1- strict monitoring of effectiveness of HD machines
2- duplex on vascular access to exclude stenosis or any other problems
3- follow up s.cr ad po4 after increasing HD frequency
4- exclude any dermatological problems
5- vit D assay
ESRD on regular hemodialysis with hypocalcemia and hyperphosphatemia causing 2ry hyperparathyroidism.
plan:
dietitian review, try daily or noctural dialysis for adequate phosphate homestasis and additon of phosphate binders.although calcium based binder not 1st choice but it will correct hypocalcemia. regarding itching correction of dryness, antihistaminics and if resistant we can try UV.
We have to check dialysis adequecy, vit D, serum albumin
ESRD with2nd hyperpathyrodsim (Renal OD)
High iPTH , hyperphosphatemia and hypocalcima
B improve adequacy of RRT ( time filter blood pump diylstae flow rate and access
Dietary referral
ca binder for short time and iron binder type
start parcalcitol with repeat ca and phos within 2 weeks
skin moist antihistamine if not improve gabapentin + tacrilums cream and opioid
c
vit d level and correct if low
SBAP
albumin
Ddxa
x-ray for calcification
A. Interpret the previous laboratory investigations.
CKD -MBD with SHPT and hypocalcemia and hyperphosphatemia
Give a management plan for this case.
as he has low Ca and Po4 then CA base phosphate binder is better along with low phosphate diet. His PTH is high and according to the KIDIGO guideline, this level needs to deal with.
This patient will need to check her Vet d level as well if low need to have vIT d supplements and this will increase her CA level
we can not start him on Cacimmetic GANET AT this stage as this will aggravate her hypocalcemia, but we can start him on paricalcitol which is vital d analogue and will increase the. Ca level and decrease the PTH level
Still, this patient needs to check his kT/v and we may need to optimize his dialysis.
A. Provide an explanation for the prior laboratory experiments.
CKD-MBD with hypocalcemia, hyerphosphatemia and SHPT .
B. Give a management plan for this case.
Improve dialysis adequacy by using high flux filter and proper dialysis dose.
Low dietary phosphate
Use of calcium based ph. binders with meal and between meals to improve the calcium level.
Use of non-calcium binder to prevent tissue calcification.
Use of vitamin D
Use of active vitamin D with close monitoring for PTH to prevent ABD.
Use of calcimimatic drugs .
For uremic pruritus, use of skin emollient, anti -histamines, and if resistant we can use gabapentin and opioid agonist.
C. What other investigations do you recommend?
Follow up for ca , p , iPTH
BSAP
Vitamin D level
Abdomenal X-RAY lateral view
Echocardiogram
Sestamibi scan for Parathyroid gland.
1* has CKD-MBD manifested as itching in addition to hypocalcimia hyperphosphatemia and hyperparathyroidism
2* restrict phosphate rich diet, use phosphote binder, check for dialysis adequacy and increase dialysis dose
Use emollient, avoid scratch , use antihistamine drugs
3* bone specific alkaline phosphotase, 25(OH)vitamin D, 1,25(OH) 2 vitamin D, Echocardiography, x ray survay for vascular calcification
A:
Patient has CKD-MBD manifested by;
With symptomatic hyperphosphatemia.
B:
C:
Interpret the previous laboratory investigations.
ESRD, with low Ca corr, high Ph and iPTH
Give a management plan for this case.
Looking at the patient’s labs results, he has high bone turnover- heading toward Osteitis Fibrosa type of CKD-MBD
What other investigations do you recommend?
Bone profile: BsALP, vit D
BTMs: P1NP
DXA scan
Cardiac evaluation
1- he has hyperphosphatemia, hyocalcemia and secondary hyperparathyroidism.
2-to be treated with low phosphate diet and calcium phosphate binder with meals .
antihistamine for itchiness
pregabalin
we can refer him to dermatology if no improvement.
3- is the patient complained to his dialysis or no
dialysis adequacy
vitamin D level and alkaline phosphatase
dexa scan
. interpretation
CKD5D complicated by hypocalcemia, hyperphosphatemia, and elevated iPTH level
( SHPT) itching, due hyperphosphatemia or in adequate dialysis.
Management
REVIEW HIS MEDICATION
1- Intensive nocturnal .dialysis.
2-follow up by dietician
3-use calcium phosphate binder.
4-antihistaminic.
5-opioid agonist (short acting)
other investigations
measure adequacy of dialysis( URR-PEW-KT/V)
25(OH) Vit D
.BSAP Ca, P ,every month. iPTH every 3 months
Alkaline phosphatase specific to bone
Lateral ABD-X- ray
ECHO
A. The patient has hyperphosphatemia, hyocalcemia and secondary hyperparathyroidism based on a terminal kidney disease.
B. The patient should be put on low phosphate diet, it is very important to take phosphate lowering meds while eating like Renagel 800mg 2-2-2-0 p.o
Then Dekristol 20000IE every week and if calcium didn’t increase next month then add calcitriol 0.5 mg 1 x every 2 day.
Antihistamine meds will be prescribed
C.I should look at BUN level becouse high BUN will cause pruritis and means that the patient isn’t enough on dialysis. So the dialysis hour will be increased maybe to 5 hours.
AP level, 25OHVitaminD and 1,25OH vitamin D and DEXA scan may be helpful to determine to assess if the patient suffer of MBD
A-S.Creatinine is compatible with a patient on regular IHD.
He has hypocalcemia and Hyperphosphatemia which are compatible with over active parathyroid gland. the PTH though is within the recommended (2-9x high normal) range
more investigations are needed to ascertain if this patient has SHPTH
B- Uremic pruritus is very difficult to treat, and has multiple pathophysiology (PO4, dryness, autoimmune etc) and is not always related to PO4.
PO4 control is required through PO4 binders, PO4 control in diet, and adequate dialysis.
Showering with cold water works for some, emolient creams, anti-histamines may work, systemic steroids are also in the armementarium.
C-
Alkaline Phosphatase (Bone specific)
DEXA
?Bone biopsy
vitD
Parathyroid imaging
A- end stage renal disease with low serum ca ,high level of po4,and high level of pth so acase of secondary hyperparathyroidism.
B- management plane control hyperphosphatemia with diet control and restrictions of po4, adquate dialysis,phosphate binder anti itching mesura with topical soozing agentsand antihistamines.
C- other investigation:
Echo cardography ,vit d level ,serum alkaline phosphatase and bone specific alkaline phosphatase , dexa scan
lab investigation revealed
hypocalcemia
hyperphosphatemia
hyperparathyrodism
management plan
review the adequacy of dialysis kt/v to providing efficient HD can improve pi and ca
review diet protocol restrict phosphorus rich diet
medication review can added
calcitriol 0.25 micgram
phosphorus binding agent
calcimimetic medication
anti-anemic treatment
control htn
more investigation recommended
as sonar .ct for Parathyroid
dexa for bone and bon biopsy
f/u cbc ,ca . pi , pth , alkp vitd
A. Provide an explanation for the prior laboratory experiments.
CKD5D is characterized by low Ca levels, high Pi levels, and elevated iPTH levels. This is a picture of SHPT and start to complain of complications like itchiness, which may be related to hypophosphatemia or inadequet dialysis.
B. Give a management plan for this case.
We need more history about the compliance of the patient on dialysis and his KT/V.
So, I will recommend that the dietician review the patient’s meal. Furthermore, optimizing dialysis by increasing the time
The patient has mild hypocalcemia, if asymptomatic, I will just observe without adding calcium. If symptomatic, I will add calcium to the medication.
If hyperphosphatemia persists after these measures, I will add a non-calcium phosphate binder.
repeat Ca, Pi, and BSAP every month. PTH every 1-3 months.
If itchiness persists after correction of hyperphosphatemia and confirmation of dialysis adequacy, gabapentin, a short-acting antihistaminic, or the new opioid agonist is administered.
C. What other investigations do you recommend?
25(OH) Vit D level
Alkaline phosphatase specific to bone
Lateral ABD-X- ray
KT/V
ECHO
ESKD , DIALYSIS WITH 2RY HYPERPARATHYROIEDISM NEEDS VIT D LEVEL , DIET CONTROL , ADEQUATE DIALYSIS , ANTI PRURITIC MEDICATION SYMPTOMATIC TREATMENT , FURTHER INVESTIGATION FOR HYPERPARATHYROIEDISM COMPLICATIONS INCLUDING VASCULAR CALCIFICATION , DERMATOLOGY CONSULTATION FOR UVB MAY BE WILL HELP FOR HIS SYMPTOMS
INTERTRETATION:
MANAGEMENT:
OTHER INVESTIGATIONS:
A-CKD 5D with CKD-MBD >>SHPT (low calcium and high phosphorous ,high PTH )
B-1-check adequacy of HD and increase frequency or duration of dialysis session ,high flux HDF
2-dietary restriction of phosphate to 800 –1000 mg/day (avoid inorganic phosphate )
3-use po4 binder like sevelamer
4-dialysate ca 1.5 mmol/l
5- fu bone profile and PTH
6-sx treatment of itching (antihistaminics ,gapabentin )
c-order serum and bone alkaline phosphatase
25(oh)D
assess for vascular calcification (lateral abdominal XR ) ECHO
iron profile and ferritin
cbc
A.Interpret the previous laboratory investigations.
B.Give a management plan for this case.
-Management is multi-disciplinary: Nephrologist / Dietitian / psychologist & social worker
-Simple things:
C. What other investigations do you recommend?
1.Lateral abdominal X-ray ; other X-rays may be hands, pelvis, and lumbar spine
2.Echo
3.Cardiac CT= the burden of the coronary calcification
A. Interpret the previous laboratory investigations.
B. Give a management plan for this case.
1- oral antihistaminics as Cetirizine.
2- Neuroleptics such as Gabapentin or pregabalin.
3- phototherapy as PUVA
C. What other investigations do you recommend?