A 52-year-old woman with end stage kidney disease secondary to hypertension complains of feeling increasingly bony aches and tiredness. She is currently receiving renal replacement therapy via hemodialysis. Her current medications include ramipril, aspirin, calcium carbonate and erythropoietin.
On examination, the pulse rate is 73 – regular and the blood pressure 138/74 mmHg. There is a functioning brachiocephalic arteriovenous fistula in the left arm. The patient’s labs are shown in table 1
Test
Value
S. Creatinine
3.9 mg/dL
S. Corrected Calcium
7.9 mg/dL
S. Phosphorus
6.9 mg/dL
iPTH
450 pg/mL
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A- Interpret the above investigations.
B- Would you recommend further investigations for this patient?
A- Interpret the above investigations.
The patient has hypocalcemia, hyperphosphatemia and hyperparathyroidism, picture of secondary hyperparathyrpidism. iPTH is higher than the target according to KDIGO guuidelines (2-9 normal level)
B- Would you recommend further investigations for this patient?
Yes, vit D level, ALP a bone turnover marker and DEXA scan
A- Interpret the above investigations.
hypocalcemia and hyperphosphatemia
hyperparathyroidism B- Would you recommend further investigations for this patient?yes i would recommend to check vit D , ALP,
DEXA scan
Model answers by the board: A. Interpret the above investigations.
The patient presented with hypocalcemia and hyperphosphatemia. PTH level is higher than target range according to KDIGO guidelines (2-9 folds of upper limit of normal). So, these abnormalities are the cause of the patient’s presentation.
B. Would you recommend further investigations for this patient?
Total alkaline phosphatase helps in determining the type of renal osteodystrophy of either high or low turnover bone disease.25 (OH) vitamin D should be assessed because its inhibitory effect on PTH level so hypovitaminosis D is associated with high PTH level and hypocalcemia. DEXA scan is used to diagnose BMD abnormalities that may be present in end stage kidney disease patients.
A- Interpret the above investigations.Hypocalcemia- Hyperphosphatemia-High PTH due to secondary hyperparathyroidism B- Would you recommend further investigations for this patient?
al of these labs are consist with wirh hyperparathyroidism, as there are hypercalcemia, hyperphosphatemia, and high PTH almost 6 folds the upper limit.
Would you recommend further investigations for this patient?
we need to check bone specific alkaline phosphatase, to do DEXA scan to rule out osteoporos as ,pt is post menopausal
A- Interpret the above investigations.
Showing low level ca and hyperphosphatemia and elevated pth so acase of secondary hyperparathyroidism
B- Would you recommend further
investigations for this patient?
Vit d level
Bone specific alkaline phosphatase dexa scan
Interpret the above investigations.CKD 5D 2 nd hyperparathyroidism with hyperphosphatemia and hypocalcemia) ============== need to order alkaline phosphatase 25(OH) vitamin d and dexa scan
Interpret the above investigations.this patient has SHPTH with hypocalcemia and hyperphophatemia in CKD stage 5D
Would you recommend further investigations for this patient?i will need to assesse this patient type of ROD for that we need to check for the following:
check bone specific ALP
need to check for 25 HO vit D level
will send for DEXA and TBS
Interpret the above investigations.CKD 5D
sHPT (hyperphosphatemia and hypocalcemia)
==============
i order bone spesific alkaline phosphatase
25(OH)vitamin d
dexa scan
A- Interpret the above investigations.hypocalcemia, hyperphosphatemia, and PTH within normal limits. an early manifestation of secondary hyperparathyroidism
B- Would you recommend further investigations for this patient?
S. magnesium, 25OH vitamin D, BSAP, DEXA, lateral abdominal x-ray, and echo.
A bone biopsy is only indicated if symptoms persist in spite of the correction of the electrolytes.
A- Interpret the above investigations.the lab . revealed
hypocalcemia
hyper phosphatemia
hyper PTH more than 2-9 fold
B- Would you recommend further investigations for this patient?
further investigatin
added vit.D level
ALP or BALP
and DEXA for bone study
and bone biopsy for confirm diagnosis
A- a case of renal impairment , hypocalcemia , hyperphosphatemia with increased iPTH ( within the target for this population )
B – vit D assay , alkaline phosphatase , DEXA scan and if osteoporosis present , bone biopsy maybe needed before starting treatment
A- Interpret the above investigations. Patient has CKD 5D with hypocalcemia , hyperphosphatemia and high PTH. B- Would you recommend further investigations for this patient? Yes , I will do Kt/V , 25 (OH )vitamin D, alk. phosphatase ( and if available (bSALP), Abdominal x ray lateral view , ECHO, BMD dexa scan , other serum electrolytes , CBC with iron profile , s.aluminium also
A- Interpret the above investigations.CKD 5D
hypocalcemia with hyperphosphatemia and elevated PTH (sHPT)
B- Would you recommend further investigations for this patient?I ORDER bSALP ,Abdominal x ray lateral view ,ECHO
dexa scan
25 (OH )vitamin D
CBC and electrolyte for tiredness
test
A secondary hyperparathyroidism
BÂ vitamin D, ALP Dexa scan
A- Interpret the above investigations.
The patient has hypocalcemia, hyperphosphatemia and hyperparathyroidism, picture of secondary hyperparathyrpidism. iPTH is higher than the target according to KDIGO guuidelines (2-9 normal level)
B- Would you recommend further investigations for this patient?
Yes, vit D level, ALP a bone turnover marker and DEXA scan
A- Interpret the above investigations.
Hypocalcemia, hyperphosphatemia with high PTH keeping with SHPT
B- Would you recommend further investigations for this patient?
A-case of ESRD with hyperphosphatemia and hypocalcemia with normal PTH
B-ALP-VD
DXA scan
A- Interpret the above investigations.
ESRD with hyperphosphatemia and secondary hyperparathyroidism due to hypocalcemia.
B- Would you recommend further investigations for this patient?
BsALP, Vit D, BTMs and DXA scan
A- Interpret the above investigations.
hypocalcemia and hyperphosphatemia
hyperparathyroidism
B- Would you recommend further investigations for this patient?yes i would recommend to check vit D , ALP,
DEXA scan
Model answers by the board:
A. Interpret the above investigations.
The patient presented with hypocalcemia and hyperphosphatemia. PTH level is higher than target range according to KDIGO guidelines (2-9 folds of upper limit of normal). So, these abnormalities are the cause of the patient’s presentation.
B. Would you recommend further investigations for this patient?
Total alkaline phosphatase helps in determining the type of renal osteodystrophy of either high or low turnover bone disease.25 (OH) vitamin D should be assessed because its inhibitory effect on PTH level so hypovitaminosis D is associated with high PTH level and hypocalcemia. DEXA scan is used to diagnose BMD abnormalities that may be present in end stage kidney disease patients.
A.Hypocalcemia, hyperphosphatemia with secondary hyperparathyroidism.
B.Vitamin D levels and BALP. DEXA scan
A- Interpret the above investigations.Hypocalcemia- Hyperphosphatemia-High PTH due to secondary hyperparathyroidism
B- Would you recommend further investigations for this patient?
A- Interpret the above investigations.
Hypocalcemia- Hyperphosphatemia-High PTH consistent with SHPT
B- Would you recommend further investigations for this patient?
25(OH)Vitamin D, BSAP, Dexa Scan
Hypocalcemia hyperphosphatemia with a mild secondary elevation of PTH. I will check for vitamin D, a Dexa scan, and ALP (or BSAP).
Interpret the above investigations.
hypocalcemia
hyperphosphatemia
secondary hyperparathyroidism
Would you recommend further investigations for this patient?
yes
i need BSAP , vitamin D level , DEXA scan .
A- Interpret the above investigations.
Hypocalcimia, hyperphosphatemia and hyperparathyroidism
B- Would you recommend further investigations for this patient?
BSAP, 24OH vitamin D, DXA Scan, lateral x ray of the abdomen, echocardiography
al of these labs are consist with wirh hyperparathyroidism, as there are hypercalcemia, hyperphosphatemia, and high PTH almost 6 folds the upper limit.
Would you recommend further investigations for this patient?
we need to check bone specific alkaline phosphatase, to do DEXA scan to rule out osteoporos as ,pt is post menopausal
A- Interpret the above investigations.
-Patient has hypocalcemia and hyperphosphatemia, iPTH is with the KDIGO recommendation
B- Would you recommend further investigations for this patient?-bALP, vitaminD
A- Interpret the above investigations.
Showing low level ca and hyperphosphatemia and elevated pth so acase of secondary hyperparathyroidism
B- Would you recommend further
investigations for this patient?
Vit d level
Bone specific alkaline phosphatase dexa scan
A- 2nd hyper PTH with low ca and high phos
b- mg vit d and bone specific alk and dexa
Interpret the above investigations.
Would you recommend further investigations for this patient?
A case of hypocalcemia, hyperphosphatemia and secondary hyperparathyroidism.
serum alkaline phosphatase or bone specific alkaline phosphatase
serum 25 OH vitamin d
serum magnesium
DEXA scan
Interpret the above investigations.CKD 5D
2 nd hyperparathyroidism with hyperphosphatemia and hypocalcemia)
==============
need to order alkaline phosphatase
25(OH) vitamin d and dexa scan
Interpret the above investigations.this patient has SHPTH with hypocalcemia and hyperphophatemia in CKD stage 5D
Would you recommend further investigations for this patient?i will need to assesse this patient type of ROD for that we need to check for the following:
check bone specific ALP
need to check for 25 HO vit D level
will send for DEXA and TBS
Interpret the above investigations.CKD 5D
sHPT (hyperphosphatemia and hypocalcemia)
==============
i order bone spesific alkaline phosphatase
25(OH)vitamin d
dexa scan
A- Interpret the above investigations.
B- Would you recommend further investigations for this patient?
A- Interpret the above investigations.
B- Would you recommend further investigations for this patient?yes. I will recommend the following :
A- Interpret the above investigations.
B- Would you recommend further investigations for this patient?
A- Interpret the above investigations.
B- Would you recommend further investigations for this patient?
A- Interpret the above investigations.hypocalcemia, hyperphosphatemia, and PTH within normal limits. an early manifestation of secondary hyperparathyroidism
B- Would you recommend further investigations for this patient?
S. magnesium, 25OH vitamin D, BSAP, DEXA, lateral abdominal x-ray, and echo.
A bone biopsy is only indicated if symptoms persist in spite of the correction of the electrolytes.
A- Interpret the above investigations.the lab . revealed
hypocalcemia
hyper phosphatemia
hyper PTH more than 2-9 fold
B- Would you recommend further investigations for this patient?
further investigatin
added vit.D level
ALP or BALP
and DEXA for bone study
and bone biopsy for confirm diagnosis
A- a case of renal impairment , hypocalcemia , hyperphosphatemia with increased iPTH ( within the target for this population )
B – vit D assay , alkaline phosphatase , DEXA scan and if osteoporosis present , bone biopsy maybe needed before starting treatment
A- Interpret the above investigations.
Patient has CKD 5D with hypocalcemia , hyperphosphatemia and high PTH.
B- Would you recommend further investigations for this patient?
Yes , I will do Kt/V , 25 (OH )vitamin D, alk. phosphatase ( and if available (bSALP), Abdominal x ray lateral view , ECHO, BMD dexa scan , other serum electrolytes , CBC with iron profile , s.aluminium also
A- Interpret the above investigations.CKD 5D
hypocalcemia with hyperphosphatemia and elevated PTH (sHPT)
B- Would you recommend further investigations for this patient?I ORDER bSALP ,Abdominal x ray lateral view ,ECHO
dexa scan
25 (OH )vitamin D
CBC and electrolyte for tiredness