The patient has been started on oral calcium carbonate, Lanthanum, and vitamin D analogue supplements. However, his symptoms are not improving. A repeat PTH three months later was 840 pg/mL and corrected serum calcium was 8.5 mg/dL.
D. What might be the best strategy to control the patient’s condition?
E. Discuss the rationale of parathyroidectomy in this case?
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Strategy to control the condition
Rationale of parathyroidectomy
D. What might be the best strategy to control the patient’s condition?
– Dietary phosphorus restriction
– Increased dialysis duration
– Non Ca based PO4 binders
– A combination of cinacalcet and calcitriol or synthetic vitamin D.
E. Discuss the rationale of parathyroidectomy in this case?
Because iPTH > 800,and if no respond to medical management. specially in presence of persistent hypercalcemia, hyperphosphatemia, bone pain, pruritis or calciphylaxis, parathyroidectomy may be necessary
I think by first you need to adequetly reduce PO4 then use calcium sensing receptor inhitbitors like cinacalcit
parathyroidectomy may be a cost effective way to recude PTH, but first you need to determine some blood tests, like bone specific alkaline phsophatase, do US for parathyroid gland to decide if there is visible adenoma or diffuse hyperplasia and radioactive studies.
D
Combination of
*Dietary PO4 restriction
*increased dialysis adequacy
*Calcimemetics
*Non Ca based PO4 binders
*VDRAs can be used if the above measures reduce PO4
E
there is a good chance that the above medical management may fail because iPTH > 800, and that the Parathyroid gland may already be in the stage of Nodular Hyperplasia and it might not be responsive to Medical management.
if this is the case Parathyroidectomy may be warranted
D. What might be the best strategy to control the patient’s condition?
I would like to take detailed history about how he/she takes Ca carb tabs?, and what is the dose? How much Ca in dialysate? I also would like to know what form of VD analogue he is on; oral or IV. If on oral form, I might change to IV during the dialysis sessions for better compliance. I should maintain Ca in a good level, before I go to next step of starting calcimimetic drug to avoid further suppression of Ca. I prefer starting IV etelacalcitide rather than cinacalcet for better compliance due to less GI side effects.
E. Discuss the rationale of parathyroidectomy in this case?
If the above mentioned measures did not work, the patient would definitely need PTX.
Long duration of Parathyroid gland stimulation would lead to THPT, when the parathyroid gland will secrete autonomously irrespective of Ca level. High level of PTH has a negative impact on both CV system and bones that would lead to vascular calcification and CKD-MBD.
the best strategy to control the patient’s condition:
the patient should avoid phosphate dietary products , non calcium phosphate binders and adequate dialysis
if the PTH remains elevated, parathyroidectomy
1- control of her diet
2- adding phosphate binder and vitamin D
3- Cinacalcet
4- parathyroid us
If there is tertiary or autonomous HPT , failure of medical treatment then she need surgery
The best strategy to control patient condition
review his diet restrict phosphate products
check dialysis filter, duration, adequacy,, extend dialysis duration or use nocturnal HD, keep dialyzate ca 1.25-1,55meq/ml
the truth i will try to decrease phosphate by non ca containing phophate binder and , avoiding ca containing phosphate binder to avoid vascular or tissue calcification may postpond vit D analogues till correcting phosphate level
if ca acceptable start calcimimitics if not responding well add vid D analogues
Radiological assessment for parathyroid gland , if patient has autonomous adenoma or persistent refractory hyperparathyroid with high PTH, and related parameter for 3-6m then patient candidate for parathyroidectomy KDIGO 2017
D. After diet control, increasing dialysis time and adequacy, replenish vitamin D stores, active vit D titration, compliance to medications,,, addition af calcimimetics (with dose titration according to responce) +/- aledronate.
E. Parathyroidectomy if failed medical treatment >6mo, valvular/vascular calcification, or calciphylaxis
The best strategy to control the pt. condition
1-diet control -restrict phosphate rich diet
2- adequate dialysis
3- start non ca- phosphorus binding
4-use cinacalcet as calcimimetic
f/u and adjust dose every M or 2M
in no response and decrease PTH < 800pg through 3-6 m
parathyroidectomy recommended
D: Reduction of dietary phosphorus, non-calcium phosphate binding agents such as calcimimetic.
E: Parathyroidectomy is advised after the use of medical treatment such calcimimetics is not responsive for at least 3–6 months or patients permanently maintain PTH levels above 800 pg/ml.
D- the best strategy to control the pt condition low phosphorus diet improve dialysis adquacy non ca phosphate binder calcimimitic
E- the parathyroidectomy in these case not recommended yet until failure of other lines or intractable symptoms
What might be the best strategy to control the patient’s condition?
Such patients might be better treated with combination therapy of an active vitamin D analog and cinacalcet (PTH > 800).
Discuss the rationale of parathyroidectomy in this case?
Very good dr Amna.
D-diet control ,efficient dialysis .compliance to medication +using of calcimimetics.
E-parathyroidectomy in case of patient not responding to conventional medication for more than 1 Y
Thank you dr Hagar.
CKD patients with refractory hyperparathyroidism despite intensive medical treatment, specially in presence of persistent hypercalcemia, hyperphosphatemia, bone pain, intractable pruritis or/and calciphylaxis, should be considered for parathyroidectomy.
What might be the best strategy to control the patient’s condition?
Low phosphate diet
Improve HD by increasing the dose and use high flux filter or HDF.
P-binders to maximal tolerated dose.
The association of VDRAs and calcimimetics has synergistic molecular effects, and also reduces the possibility of adverse effects on calcium and serum phosphate, since the effects of one can counteract the effect of the other. If PTH is drastically reduced to levels associated with low bone turnover, the use of both should be reduced or discontinued.
Discuss the rationale of parathyroidectomy in this case?
I think in this case better to give chance to health education and medical treatment before taking decision of Parathyroidectomy .
In patients with severe secondary hyperparathyroidism who do not respond adequately to these drugs, parathyroidectomy should be considered. Although there is no agreement on the serum levels of PTH to which a parathyroidectomy should be indicated ,the most current practice is to perform a parathyroidectomy if despite an adequate medical treatment for a period of at least 3–6 months, patients perma- nently maintain PTH levels above 800 pg/ml .
Excellent dr Asmaa.
D. Ensure patient compliance, increase dialysis dose, use calcimimetic drugs.
E. Give a chance for another 3 months if no response so do parathyroidectomy.
Thankyou dr Israa.
CKD patients with refractory hyperparathyroidism despite intensive medical treatment, specially in presence of persistent hypercalcemia, hyperphosphatemia, bone pain, intractable pruritis or/and calciphylaxis, should be considered for parathyroidectomy.
D-calcimimetic agents
E- follow PTH if not response within 6 month for parathyroidectomy
Thank you dr Khaldon.
CKD patients with refractory hyperparathyroidism despite intensive medical treatment, specially in presence of persistent hypercalcemia, hyperphosphatemia, bone pain, intractable pruritis or/and calciphylaxis, should be considered for parathyroidectomy.
D:
Optimise the patients dialysis adequacy
Cinacalcet/ vit d analouges
F/up s. Ca/ph/PTH
E:
ParathyroidectomyAFTER a trial period with Cinacalcet to monitor PTH response
Thanks dr Mahmoud.
D. What might be the best strategy to control the patient’s condition?
Best Strategy for this patient will depend mainly on P control through ;
control diet .
increase dialysis adequacy ( check HD duration , check dialyzer type and size ) ,
shift to HDF.
revise dose of P binder. and increase to Maximum tolerable dose.
Start cinacalcet with low dose and gradually increase according to patient
tolerance and monitoring of serum calcium level .
we can add active Vit D with Cinacalcet after P control .
E. Discuss the rationale of parathyroidectomy in this case?
I think in this case better to give chance to health education and medical treatment before taking decision of Parathyroidectomy .
Thank you dr Ahmed.
CKD patients with refractory hyperparathyroidism despite intensive medical treatment, specially in presence of persistent hypercalcemia, hyperphosphatemia, bone pain, intractable pruritis or/and calciphylaxis, should be considered for parathyroidectomy.
D. What might be the best strategy to control the patient’s condition?
E. Discuss the rationale of parathyroidectomy in this case?
The best strategy to control the patient’s condition:
1-Diatery phosphate restriction.
2-Increase dialysis dose either by prescribing prolonged nocturnal hemodialysis or short more frequent hemodialysis (2.5–3.5 h per dialysis session), or using peritoneal dialysis
3-Start calcimimitics (with smallest doses of calcium containing phosphate binders to avoid associated hypocalcemia)
4-Use dialysate calcium concentrations between 1.25 and 1.50 mmol/l (2.5 and 3.0 mEq/l
5- Continue non calcium containing phosphate binders
6- Although vitamin D analogue or calcitriol increase calcium and suppress PTH BUT it increase phosphorus SO we can reduce dose of it or stop it according to serum phosphorus level
The most current practice is to perform a parathyroidectomy if despite an adequate medical treatment for a period of at least 3–6 months, patients permanently maintain PTH levels above 800 pg/ml
D: Optimise the patients dialysis adequacy
Optimise the calcium levels
Start in Cinacalcet
E: Parathyroidectomy:
Is an option for the patient, but give a trial period with Cinacalcet to monitor PTH response
I will maximize the dose of D vitamin analogue (10 mcg-15 mcg/3 times at the dialysis session ends). will increase cinacalcet from 30 or 60 (if so) up to 90. Early Thyroidectomy. Despite all measures at a late stage, thyroidectomy may be needed, I will check thyroid UDG or scintigraphy later but not before maximizing the doses. my aim is early management before nodularity ensues)
Q1: Control po4 is very important and after correction of hypocalcemia we may add cinacalcet starting with low dose with gradual increasing according to PTh level and patients compliance, measuring Vit D level and correction of Vid D insufficiency/deficiency, add cinacalcet alone or with active Vit d analogue may improve patients condition.
Q2: Parathyroidectomy still option for patients to relife is complain it will depend on serial alkaline phosphatase level, patients symptoms, trend of PTH level, patients compliance to cinacalcet.
D. I will try to use mimpara , or parsabiv after every cession of HD.
We should check the adequacy of iHD, phosphate level (if normalized or not) , vitamin D level.
We will gave the patient a chance for 3-6 month, mimpara or parsabiv should be increased to maxmal dosis in this period. If PTH still high then parathyroidectomy is the solution (Question E).This is because parathyroid gland receptors have resistance to medical treatment because of monoclonal/ nodal proliferation.
Great dr Nour.
Q1
Thanks dr Ashraf.
The calcium-sensing receptors regulate the secretion of parathyroid hormone. Calcimimetic agents increase the sensitivity of the calcium-sensing receptor to extracellular calcium ions, inhibit the release of parathyroid hormone, and lower parathyroid hormone levels. It is considered more effective than active vitamin D in lowering serum PTH. Using either calcimimetic alone or in combination with calcitriol are effective in lowering PTH level. Furthermore, contrary to vit D analogues, calcimimetics put the patient on a negative calcium and phosphorus balance.
D. What might be the best strategy to control the patient’s condition?
I will recommend Cinacalcet plus Vit-D or/ Vit-D analogous and titrate the dose if the patient can tolerate it until control of PTH(2-9 Time upper limit).
E. Discuss the rationale of parathyroidectomy in this case?
If the medical treatment fails to control the PTH.
There is no consensus about the iPTH level needed to perform a parathyroidectomy.
we will depend on the persistent elevation of the iPTH in addition to
Persistent high PO4 or bony pain/itchiness, calciphylaxis.
Great job dr Weam.
D- it is advised to use calcimimetics as cinacalcet in this patient after correcting hypocalcemia to act on ca sensing receptors in parathyroid gland to suppress PTH level to the desired target.
E – parathyroidectomy may have a role if still persistant elevated PTH levels with symptoms of bone pain inspite of use of all lines of ttt including oral calcium , po4 binders , vit D analouges and cinalcet.
Very good dr Mark.
D-
Adequate Hd(at least 12 hour session/week)
Strict control to inorganic phosphate diet
Add Cinacalcet 30 mg and fu bone profile and PTH
E-
Parathyroidectomy remains valid especially if cinacalcet and fail to reduce PTH level
Great dr Emad.
CKD patients with refractory hyperparathyroidism despite intensive medical treatment, specially in presence of persistent hypercalcemia, hyperphosphatemia, bone pain, intractable pruritis or/and calciphylaxis, should be considered for parathyroidectomy.
IF AFTER ADDING CALCIMEMETIC , VIT D ANALOGUE , DIET CONTROL AND ADEQUATE DIALYISIS NO IMPROVEMENT OF HIS PTH MAY BE WILL BE BETTER TO GO FOR SURGERY
Thank you dr Abdulrahman.
D adding alfacalcidol might be an option to avoid parathryoidectomy. alfacalcidol will increase both calcium and phosphate. might be worth omitting calcium carbonate. cinacalcet could be used but could cause hypocalcaemia
E If patient is symptomatic despite alfacalcidol it means parathyroidectomy will means no PTH and therefore stop symptoms tho might need to look out for hungry bone syndrome post op and adynamic bone disease. it might help patient anaemia control and make patient fitter for a renal transplant long run
Thanks dr Muhammad.
CKD patients with refractory hyperparathyroidism despite intensive medical treatment, specially in presence of persistent hypercalcemia, hyperphosphatemia, bone pain, intractable pruritis or/and calciphylaxis, should be considered for parathyroidectomy.
D. What might be the best strategy to control the patient’s condition?
E. Discuss the rationale of parathyroidectomy in this case?
Agree. Yet, A combination of calcimimetics and calcitriol may have a role in such a case.