A 59-year-old man with a long history of hypertension and 10-months history of chronic kidney disease, presents to the clinic for routine follow-up. His current medications include lisinopril, amlodipine, and oral ferrous sulfate. On physical examination, blood pressure is 122/78 and pulse is 82 per minute. In general, he is a well-appearing man. His labs are shown in table 1.
|
Test |
Value |
|
S. Creatinine |
2.9 mg/dL |
|
Hgb |
10.3 g/dL |
|
S, Corrected Calcium |
9.7 mg/dL |
|
S. Phosphorus |
4.5 mg/dL |
|
S. Potassium |
4.7 mmol/L |
A. Interpret the above laboratory investigations.
B. Would you recommend any further lab for this patient?
C. Appraise the rationale of active vitamin D usage at this stage.
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Lab results
Advanced CKD with anemia, with an upper limit of normal K, Pi, and normal calcium.
Other recommended labs
The rationale of active vitD
A. Interpret the above laboratory investigations.
CKD patient has anemia with normal Ca ,P , K
B. Would you recommend any further lab for this patient?
Monitoring of iron study , ca , phosphorus, PTH, vitamin D, S.alb every 1-3 months
ECG , Ecchocardiogram
Lipid panel, Hba1c , LFT
KUB ultrasound
C. Appraise the rationale of active vitamin D usage at this stage.
KDIGO 2017 Recommendations:
Calcitriol and vitamin D analogs should not be used frequently in adult patients with CKD G3a-G5 who are not on dialysis (2C).
Calcitriol and vitamin D analogs should be used only by people with CKD G4-G5 who have severe and progressive hyperparathyroidism (Not Graded)
the patient is anemic, stage 3-4 CKD , but not yet in need for vit D analogues
I will do iron studies, ferritin iron level, transferritin saturation, folate andvIt b levels, Vit D level, PTH
A
This gentleman has eGFR of 24, so he is in stage 4 CKD
He is anemic because of combination of iron deficiency (inhibited iron absorption), and reduced Erythropoiesis because of his reduced Nephron mass
compensatory mechanisms still can maintain his Ca and PO4 level within normal (PO4 in upper normal)
Potassium homeostasis is expected to be maintained at this level of kidney function
B
*Iron studies
*Vitamin D levels
*Bone Specific ALP
*iPTH
*Lateral Abdominal XR
C
Active Vitamin D may be used in this stage if iPTH and ALP indicate high turnover.
otherwise it is better reserved for later stages
Interpretation of the laboratory investigation:
this is a CKD- related anemia, normal serum calcium and phosphorus
I recommend further lab
vit D level, ALP and iPTH
Appraisal for active vit D
not routinely used and better to be saved for advanced stages of CKD
A anaemia likely ckd related, calcium normal . phosphate higher end of normal ,
B pth ,vitamin D, ALP
C there is no evidence to use active vitamin D in ckd 4/5
A. Interpret the above laboratory investigations.
CKD patient with anemia and normal Ca, PH, and K levels
B. Would you recommend any further lab for this patient?
I usually do full work up to check for any other secondary causes of CKD than only HTN. I would send for MM, virology, vasculitis work up.
Concerning the long standing effect of CKD on vascular system and bone, I would order the following:
C. Appraise the rationale of active vitamin D usage at this stage
At this stage, klotho level would be low leading to high FGF23 that decreasing Vit D3 formation by inhibiting 1-alpha hydroxylase. Hence, I will check Vit D level; if it is low (based on general population reference range), will start cholecalciferol to stimulate intestinal absorption of Ca and PH.
1- anemia of CKD
2- iron study and MBD investigation
3-to control SHPT
CKD with anemia , with normal PO4 and k.
i would recommend this further lab such as . PTH , Ferritin. ALP,and vitamin D
should not be rushed to active vitamin D
A. Labs : CKD-G4 (eGFR 24ml/min), anemia
B. Further labs: ALP (total or BSAP)/1-3 mo, PTH/6-12mo, vitamin D, S.alb, iron profile, ferritin, VBG
C. Active vitamin D is given if SHPT, not as routine use
A: Chronic Kidney Disease with an associated Anemia
B: Iron studies
PTH and Vitamin D
ALP
C: Should be supplemented if deficient
A. Interpret the above laboratory investigations
CKD 4(eGFR 24ml/min/1.73m2 with mild anemia
B. Would you recommend any further lab for this patient?
Lab: Iron study, albumin, vitamin B12, VD, PTH, ALP
Monitoring of ca, p, and iPTH every 1-3 months.
Imaging: KUB ultrasound
C.Appraise the rationale of active vitamin D usage at this stage.
It will be according to the level of VD and PTH but not routinely given as may aggravate the hyperparathyroidism
a-the lab investigation in this pt. ckd mild anemia compansated ca level and phosphorus and normal k level
b- recommendation for this pt. fu 6-12m added alkaline phosphatase , pth and vit-D
and assessment anemia
c- use of vit-d should be according level of vit-d maintain at 20- 40ng/ml
A- interpretation of investigation renal impairment S4 with anemia.
B-Recommended other lab pth level vit d level alkaline phosphatase and tsat level
C- the use of vit d level in these stage according to pth level .
Interpret the above laboratory investigations
Male patient with CKD stage 4 , GFR 24, with anemia
Would you recommend any further lab for this patient?
PTH every 6-12m, bone specific alk;ine phosphatase every 12m, iron profile every 3-6m, inflammatory markers
Appraise the rationale of active vitamin D usage at this stage
as excess vit D may shift high turnover bone disease to low turnover, and the target PTH in non dialysis CKD 3a-5 not known, routine giving vit D to Ckd not recommended and should be given if theres severe progressive hyperparathyrodism according to KDIGO2017
A- stage 4 CKD with mild anemia and normal levels of other parameters
B- urine analysis
PTH ,base alkaline phosphatase and V.25
iron study, folic acid
C-according to his PTH level but not recommended to used routinely.
Thankyou dr Hagar.
Recommendations of KDIGO 2017:
Interpret the above laboratory investigations
Would you recommend any further lab for this patient?
KDIGO 2017 recommendations:
I will treat it with vitamin D if deficient; given he has acceptable calcium and phosphate level.
Great dr Amna.
25- OH vitamin D level should be screened also and treated according to the general populations.
A. Interpret the above laboratory investigations.
stage 4 CKD .
calcium, k and phosphorus are in range.
anemia matching with CKD stage.
B. Would you recommend any further lab for this patient?
Bone-specific alkaline phosphatase,
PTH
25-vitamin D.
Iron study .
C. Appraise the rationale of active vitamin D usage at this stage.
according to PTH level .
Thank you dr Ahmed.
Recommendations of KDIGO 2017:
A. Interpret the above laboratory investigations.
CKD stage 4
Anemia
Normal Ca ,P , K
B. Would you recommend any further lab for this patient?
Baseline investigations
Iron study
PTH
BSALP
Monitoring of ca , p, and iPTH every 1-3 months.
C. Appraise the rationale of active vitamin D usage at this stage.
The recommendations for the use of calcitriol or any other form of active vitamin D receptor activator differs, in CKD patients stages 3–5, the use of calcitriol and active vitamin D analogs is not recommended as routine and they are reserved for CKD patients stages 4–5 with severe and progressive hyperparathyroidism, though these limitations are not worldwide accepted .
well done dr Asmaa.
A. patient in ckd stage 4 , anemia, normal calcium, phosphorous and electrolytes
B. Need iron study, 1,25 vitD, 25 vit D, s. Alkaline phosphotase and PTH
C. If vitamin D deficiency so treatment will be needed specially use of calcidol, as active vitamin D causes increase intestinal absorption of calcium and phosphorus
A- ckd stag 4 eGFR 24 with anemia mostly due ckd
k ca and phos intarget
b- anemia work up with iron profile
bone sepcific alkalain
albumin level
iPTH
vit d
c- depend if PtH level within target or need to control in same level ckd
A. Interpret the above laboratory investigations.
-stage 4 CKD .
-calcium, k and phosphorus are in range.
-anemia matching with CKD stage..
B – Would you recommend any further lab for this patient
Bone-specific alkaline phosphatase,
25-vitamin D.
TSAT .S.iron , ferritine .
C. Appraise the rationale of active vitamin D usage at this stage.
Not routinely recommended in such case.
A. Interpret the above laboratory investigations?
B. Would you recommend any further lab for this patient?
Absolutely yes, we are given long history of hypertension and we know that hypertension can a cause of CKD and CKD as well can present with hypertension. Therefore, my own opinion is to investigate him further for other etiologies of CKD:
C. Appraise the rationale of active vitamin D usage at this stage?
This patient is having normal Ca and Phophate so far ,his eGFR is 24ml/mint CKD stge 4
he has Anemia of chronic illnes with normal k level
he is HTN on dual nmedication with good control so far .
According to the recent data better to avoid use of calcitrol and calcidol to avoid hypercalcemia .
Would you recommend any further lab for this patient?
yes, i will manage his anemia with full anemia work up including iron profile .PTH level,ALP LEVEL .
Appraise the rationale of active vitamin D usage at this stage.
will check PTH if he has SHPTH will use the vet D analoge
A 59-year-old man with longstanding HTN,CKD with eGFR 24ml/min/1.73m2(stage 4)
Lab investigations: shows mild anaemia,normal serum calcium ,phosphorus and potassium.
Recommended lab:
PTH level, vitamin D level , alkaline phosphatase(total and bone specific).
work up of anaemia: RC,coombs,LDH,serum iron ,ferritin,TSAT, plasma protein electrophoresis.
The recommendations for the use of calcitriol or any other form of active vitamin D receptor activator differs, in CKD patients stages 3–5, the use of calcitriol and active vitamin D analogs is not recommended as routine and they are reserved for CKD patients stages 4–5 with severe and progressive hyperparathyroidism, though these limitations are not worldwide accepted
24 ml/min/1.73 m²Estimated GFR by 2021 CKD-EPI Creatinine
Stage IVCKD stage by CKD-EPI Creatinine 2021
***
I need to evaluate the PTH as well. I need 25(OH) vit. d level as well.
apart from this anaemia panel.
***
If I get low vitamin D I will replace it, according to PTH which is expected to be high I will reserve vitamin d analogues if PTH is less than 300, and will start if >450 (dose according to PTH level, starting with a low dose and titrating).
***
P/Ca is normal probably because of compensatory high PTH
A. CKD stage 4
Phosphate potassium and calcium in normal range.
B. Yes. It seems that the calcium phosphate hemostasis is normal and compensated . I will test 1,25OH vitamin D and 25 OH vitamin D and PTH level.
The level of pth may be high and we may see a vitamin D deficiency with deterioration of renal function and inhibition effect of FGF23 on 1 alpha hydroxylase.
Because a renal Anemia is a diagnosis of exclusion we should exclude other factors that lead to renal anemia so we should do further test: iron,Ferritin, transferrin-saturation, vitamin b12, folate, LDH, haptoglobin.
C. Like mentioned above, vitamin d will be used if there is vitamin d deficiency and to suppress PTH overproduction through acting on VDR then decreasing PTH gene transcription if patient suffering of secondary hyperparathyroidism.
Thank you dr Nour.
Recommendations of KDIGO 2017:
A. Interpret the above laboratory investigations.
stage 4 CKD . His calcium, k and phosphorus are within normal range. anemia matching with CKD stage..
B – Would you recommend any further lab for this patient
Bone-specific alkaline phosphatase, 25-vitamin D, and PTH.
TSAT .S.iron , ferritine .
C. Appraise the rationale of active vitamin D usage at this stage.
with CKD there increase in FGF 23 WITH decrease 1 alpha hydroxylase causes low vit-D.so Vit. D is needed to prevent the development of secondary HPT.
Thank you dr Ashraf.
According to the recommendations of KDIGO 2017:
A. Interpret the above laboratory investigations.
He has stage 4 CKD (eGFR of 24 ml/min/1.73). His calcium and phosphorus are within the accepted range. a mild degree of anemia matching his CKD stage.
B. Would you recommend any further lab for this patient?
Bone-specific alkaline phosphatase, 25-vitamin D, Iron profile and iPTH
C. Appraise the rationale of active vitamin D usage at this stage.
• The PRIMO and OPERA studies failed to demonstrate improvements in clinically relevant outcomes but did demonstrate an increased risk of hypercalcemia. Accordingly, routine use of calcitriol or its analogs in CKD G3a-G5 is no longer recommended.
If 25-hydroxy VIT-D is low, we will replace it to reach the normal range.
Very good dr Weam.
A- a case of renal impairment ( CKD stage 4) if this is the basal level of creatinine with no correctable causes of AKI with low normal HGB and normal values of calcium , phosphorus and potassium
B- total iron profile , PTH assay, urine analysis and vit D levels with uric acid
C- active vit D can be used in this patient if evidence of vit D defiency or secondary hyperparathyroidism to suppress PTH levels
Good job dr Mark.
In case of vitamin D deficiency, patients with CKD should be treated according to the general population with native vitamin D analogue not active form because the later have more suppressant effect on PTH level.
A-
CKD G4 (eGFR 24 ml/min according to CKD epi 2021)
Mild anamia
S phosphate on upper limit of normal
S calcium on normal range
B-
Assess for complications of CKD
1- anaemia workup cbc with differential and cell indices MCV
Iron profile %HRC ,CHBr,ferritin /tsat
RETICULOCYTE COUNT
Vit b12 and folat level
Crp
2-CKD-MBD
iPTH LEVEL
25(OH)D3 level
BSAP
3_test for metabolic acidosis
Serum bicarbonate
4-virology for hepatitis c,b and HIV after verbal consent
C-
Use of calcitriol and vit D analogs with severe and progressive hyperparathyroidism after correction of all modifiable factors for hyperparathyroidism and keep your eye on serum phosphate and serum calcium
Great dr Emad.
PATIENT HAS CKD STAGE 4 BASWD ON MDRD eGFR 29 , IT WILL BE OF VALUE AND NEEDS TO BE CHECKED FOR HYPERPARATHYROIEDISM , VIT D ANALOGUE MAY BE OF VALUE AFTER FULL INVESTIGATION
Thanks dr Abdulrahman.
Recommendations of KDIGO 2017:
A. Interpret the above laboratory investigations.
B. Would you recommend any further lab for this patient?
C. Appraise the rationale of active vitamin D usage at this stage.
Right!
bone specific alkaline phosphatase would be more informative to evaluate his bone health and vitamin D should not be routinely used in non-dialysis CKD patients.