Part I: A 50-yr-old male with ESKD who came in for routine follow up. He has been on maintenance hemodialysis for 2 years. The patient had a myocardial infarction requiring coronary artery bypass graft (CABG) surgery 9 months ago.
Review of his laboratory values are shown in table I
Test
Value
S. Creatinine
4.2 mg/dL
S. Corrected Calcium
10.12mg/d L
S. Phosphorus
6.9mg/d L
iPTH
92 pg/mL
A) Appraise the need for calcitriol therapy in this patient .
B) Do you suggest any other work-up for this patient?
C) Suggest the most likely management plan.
50 Comments
Radwa Ellisy
This is a case of a dynamic bone disease based on (mild hypercalcemia, near normal iPTH, and hyperphosphatemia) in an advanced CKD patient stage V
No need for vit D agonist as it would increase parathyroid suppression.
B other work up :
lateral spine X-ray for vascular calcification and echocardiography
laboratory: ALP management plan:
Stop vit D agonist
Stop calcium supplementation or calcium phosphorus binders
low dialysate calcium (1.25-1.5 mmol/l)
use of non calcium based phosphorus binders as sevelamer
A) Appraise the need for calcitriol therapy in this patient.
In the presence of mild hyper ca and HyperPh with low PTH and clinical evidence of vascular calcification, all of these point to the possibility of ABD.
The principal factor underlying ABD is either:
over suppression of PTH release (high doses of vitamin D analogs, calcium-based phosphate binders, and/or calcimimetic agents)
resistance to PTH actions on bone
So calcitriol will suppress PTH
B) Do you suggest any other workup for this patient?
BSAP as a surrogate biomarker of ABD
Evaluation of vascular calcification (eg, lateral Abd x-ray)
vit D
C) Suggest the most likely management plan. Reversal of PTH suppression — The initial approach to treatment of ABD is to allow PTH secretion to rise.
By:
using non-calcium-based phosphate binders
decreasing or stopping active vitamin D analogs;
low dialysate calcium concentration
Monitor treatment response:
PTH
BSAP
calcium, phosphate
25-hydroxyvitamin
Reversal of ABD: increase in PTH and BSAP levels and resolution of hypercalcemia (if present).
A) Appraise the need for calcitriol therapy in this patient.Patient has ESRD on HD with inappropriately low PTH indicating that patient has ABD. I don’t recommend to start on calcitriol as the patient has mildly elevated Ca and High Ph. Calcitriol will suppress PTH further. B) Do you suggest any other work-up for this patient?BTM: BsALP, P1NP
DXA scan with TBS
VFA
Lateral spine X-ray to check for aorta calcification
C) Suggest the most likely management planStop Ca carb if any taken orally
Make sure dietary Ca intake < 2000 mg per day
Decrease Ca in dialysate
Non Ca phosphate binder
Low phosphate diet
Appraise the need for calcitriol therapy in this patient .this patient does not need calcitorial Do you suggest any other work-up for this patientthis patient need xray ,echo , CT scan for finding any calcifications Suggest the most likely management plan.low calcium dialysate
low phosphate diet
A- likely abd suppressed pth . no need for calcitriol
B- Vitamin D , Bone Makers and Lateral x ray to check calcification
C- observe pth ca/po42- after stopping ca binders , low calcium dialysate stopping alphacalcidol
A)not to use calcitriol in this case
B)check ALP
c ) use low ca dialysate
efficient dialysis ,decrease diet containing phosphate
use non ca containing phosphate binder
We do not need calcitriol therapy in this patient. Ca is 10.12 mg with PTH below the target, which is more optimal around 300 +/- 50; for that reason lowering dialysate calcium to 1.25, replacing or the initiation of non-calcium binding phosphor binders (sevelamer or low dose Lantanum).
This patient has HIGh CA and PO4 with low PTH which looks like adynamic bone disease
in such area, calcitriol will suppress the PTH more.
Do you suggest any other workup for this patient?Need to check for ALP bone type to be sure of our diagnosis
Suggest the most likely management plan.diet control
use of low CA bath in dialysis
increase the frequency and the length of dialysis
non-Ca phosphate binder along with a low Phosphate diet
A. No need for calcitriol
B. Suggest echo and lat abd X ray
C. Plan ;
diet control
use non calcium containing P binder
stop alpha calcidol and calcimimetics
use low calcium dialysate
A) Appraise the need for calcitriol therapy in this patient .
The patient has high normal calcium, high phosphate and low PTH , picture goes with adynamic bone disease , there is no need for calcitriol as it will cause more suppression to PTH and cause more harm.
B) Do you suggest any other work-up for this patient?
BSAP
Lateral abdominal X R for any calcification
Echo for any valvular calcification
C) Suggest the most likely management plan.
Low phosphate diet
Avoid calcimimatics and calcitriol
Use non-calcium phosphate binders
Low calcium dialysate
A) this patient have normal calcium , high phosphorus and very slight elevated PTH. The treatment with VDR will be inappropriate because it will rise further his phosphate and calcium level what is not needed in this case and will further suppress his relative low iPTH level.
B) we can measure Bone specific AP, 25 OHVitamin D , we can measure DXA in this case.
C) we will prescribe him non-calcium containing phosphate binders. Dietary consultation and encouraging him to not take above 800-1000 mg calcium daily and to avoid phosphat rich food.
A- THIS PATIENT HAS HIGH PHOSPHOROUS , HIGH NORMAL CALCIUM ,AND INADEQUATLY ELEVATED PTH ( SUPRESSED ) SO AVOID VITD AND CALCIUM SUBLEMENTS
B- PATIENT NEEDS FOR OTHER LAB LIKE ALK. PHOSPHAASE , VIT D LEVEL , ALSO NEEDS FOR XRAY , ECHO AND CORONARY CT SCAN MY BE WILL HELP
C- NONCALCIUM PHOSPHATE BINDER , LOW CALCIUM , PROLONGED SESSIONS OF DIALYSIS , DIET CONTROL
A. Calcitriol not need to be given for this patient as he has high phosphorous and low PTH
B. Bsap, lateral x ray of the abdomen for vascular calcification, echocardiography
C. Stop calcimimetic drug or vitamin D analogs, low phosphorous containing diet, non calcium containing phosphate binders, increase dialysis adequacy.
A) Appraise the need for calcitriol therapy in this patient .no need for calcitriol therapy in this patient as he has hyperphosphatemia and low PTH level
B) Do you suggest any other work-up for this patient?i order bone specific alkaline phosphatase
abdominal x ray lateral view
Echo
C) Suggest the most likely management plan.1-dietary phosphate restriction avoid inorganic phosphate diet
2-adequate hemodialysis (high flux ,increase time or frequency of hd )
3=add sevelamer as phosphate binder
4-low calcium dialysate 1.25 mmol
5-avoid any calcium or VDRA or calcimimetics
A) Appraise the need for calcitriol therapy in this patient .
No need for adding vit D dueto pt have hyperphosphatemia and upper normal of ca with slight elevation in pth that’s parameters causing depression in pth and induce vascular calcification.
B) Do you suggest any other work-up for this patient?
Serum alkaline phosphatase and bone specific alkaline phosphatase
Echo to exclude cardiac calcification
Xary abdomen in lateral view to detect aortic calcification.
C) Suggest the most likely management plan.
Non ca containing phosphate binders
And low ca diyalisate concentration
A. Appraise the need for calcitriol therapy in this patient .
This patient most likely has adynamic bone disease (ABD) based on the low PTH and the mild hypercalcemia. The initial approach for treatment of ABD is to allow parathyroid hormone secretion to rise to improve the bone formation rate. This can be achieved by using non-calcium-based phosphate binders; decreasing or stopping active vitamin D analogs; and, for patients on dialysis, possibly by using a low-dialysate calcium concentration according to KDIGO 2017 guidelines (1).
B. Do you suggest any other work-up for this patient?
Lateral abdominal radiograph can be used to detect the presence or absence of vascular calcification, and an echocardiogram can be used to detect the presence or absence of valvular calcification, as reasonable alternatives to computed tomography-based imaging (2C). Bone-specific alkaline phosphatase can be used to evaluate bone disease because markedly high or low values predict underlying bone turnover (2B), (1).
C. Suggest the most likely management plan.
Restricting dietary phosphate intake and using non-calcium containing phosphate binders as sevelamer. Using calcitriol or oral calcium should be avoided. Suggest using a dialysate calcium concentration between 1.25 and 1.50 mmol/l. These measures help to decrease phosphorus level and guard against more decrease in PTH level that have many hazardous effects on either bone health or cardiovascular calcification.
A) Appraise the need for calcitriol therapy in this patient
This patient is suspected with Adynamic bone disease, Vitamine D analog will further increase both serum calcium and phosphate so no need to add calcitriol for this case
B) Do you suggest any other work-up for this patient?
Bone specific Alkaline phosphatase(BAP)- Vitamin D- Xray-Dexa scan- evaluate for cardiac calcification- check the dialysate calcium concentration.
C) Suggest the most likely management plan.
Correct hyperphosphatemia by using noncalcium phosphate binders and advice low diet phosphate Review dialysate calcium concentration suggest them to use low calcium dialysate
Monitor serum calcium, phosphate and PTH
Appraise the need for calcitriol therapy in this patient
no role to calcitriol in this case.
Do you suggest any other work-up for this patient?
yes , ECHO, lateral view Xray abd, review his medication ., review the dialysate.for Ca concentration, bone alk ph.
Suggest the most likely management plan: USE low ca dialysate, stop ca based ph binder, ow ca diet, stop vit -Calcimimitic, reviwe the water unit for AL .
A) Appraise the need for calcitriol therapy in this patient .
Calcitriol will increase Ca (already normal), will increase PO4 (already high) and will suppress iPTH (not needed)à No need for Calcitriol in this case.
B) Do you suggest any other work-up for this patient?
bALP, lateral spine XR, DEXA scan, VitD levels, ? bone biopsy
C) Suggest the most likely management plan. low ca dialysate, stop ca based PO4 binder, low ca diet, stop vit D, stop Calcimimitics , check dialysate water for Aluminium.
A) Appraise the need for calcitriol therapy in this patient .with calcitriol the s.Ca will increase due to increase the absorption of Ca from gut .
so no role to calcitriol in this case.
B) Do you suggest any other work-up for this patient?yes ,
A) Appraise the need for calcitriol therapy in this patient We are suspecting ABD Calcitriol therapy is not preffered for this patient . The following conditions are contraindicated with this drug: · sarcoidosis. · high amount of phosphate in the blood. · high amount of calcium in the blood. · excessive amount of vitamin D in the body. · kidney stones. · decreased kidney function.
B) Do you suggest any other work-up for this patient?
Alkaline phosphatase.
ECHO.
X-ray of upper or lower limbs for evidence of vascular calcification.
DEXA
C/ Suggest the most likely management plan.
Adequate hemodialysis
low-phosphate diet.
Avoid any calcium or vitamin D derivatives.
Follow-up of these laboratory parameter
Correction of hyperphosphatemia by non calcium, non aluminum phosphate binders
the patient has lab evidece of adynamic bone disease, high serum ca and po4, and low PTH. Addition of calcitrol will worse the conditin, increase calcium and phosphorus which will lead to more vascular calcification and suppressing PTH. we should check alkaline phosphatase and serum aluminum. plan of management include :- decreasing serum calcium by holding calcium bsed phosphate binder, decrease calcium in the dialysate
2 – decrease suppression of pth, hold vit d and its analogue or calcimimetics
3- correction of hyperphosphatemia by non calcium, non aluminum phosphate binders
A) Appraise the need for calcitriol therapy in this patient
Adding calcitriol will increase the absorption of ca and PO4 from the GIT, which will increase the serum ca and PO4, which are already high. also, calcitriol will suppress the PTH more, which is already low and reflect a dynamic bone disease
All this will increase vascular calcification.
Do you suggest any other workup for this patient?
Bone-specific alkaline phosphatase
25-OH VIT D
S.alumonium
Echo, Dexa scan, and CAC score
kt/v
C) Suggest the most likely management planCheck the calcium concentration of the dialysate and make sure it is not more than 1,5
avoid calcium and Vitamin D and vitamin D analog
Search for any source of aluminum, especially in pharmaceuticals and food preparation, and stay away from it.
Re-educate about the importance of avoiding smoking, and decreasing body weight
with close observation of ca, PO4, and PTH
A) Appraise the need for calcitriol therapy in this patient .
This guy on HD for 2 years and had history CAD
We know that, CKD pts are at high risk for CVD due to presence of traditional & non-traditional risk factors
His laboratory data showed Ca at upper limit of normal, high PO4, & iPTH < 150 pg/ml. These findings may favor the diagnosis of adynamic bone disease (ABD) although further investigations may be needed to confirm this diagnosis. ABD is a well known risk factor for CVD according to the data from the observational studies and this may explained CAD in this patient.
Calcitriol therapy is not a good idea in this case, as we are suspecting ABD and the patient is already had high Ca & high PO4 , and iPTH < 150 ,which is likey to worsen upon introduction of calcitriol.
B) Do you suggest any other work-up for this patient?– Yes,risk factors for ABD
Blood sugar for DM
Serum albumin for malnutrition
–Evidence of vascular calcifications
Lateral abdominal X-ray
Echo
Pain radiography of the hands
CAC score
–Biomarkers of bone turn over if you have it available
tAPT/ bAPT( Alkaline phosphatase)
P1NP
Scerostin
TRAP-5b
C- Suggest the most likely management plan.-This will largely depends on the risk factors for ABD;
Look for calcium-based phosphate binders/ VDRA , and stop them
Look for dialysate Ca content and make sure it is 1.25 to 1.50 mmol/l maximum
Look for any aluminum source specially in drugs and food preparation and avoid them
the lab revealed Hyperphosphatemia upper border of calcium level PTH accepted as normal no 2ry HPTH SO the no need to calcitriol >> may lead to more suppression of PTH and Hyper calcemia Start non calcium phosphate binder management plan bone assessment to rule out adynamic bone disease x-ray and DEXA , renal biopsy and follow up ca , pi , vit D and PTH
A- there is no need for calcitriol therapy for this patient as he has high normal calcium and increased po4 level with oversuppressed PTH which will be exaggerated by Vit D therapy
B- Dexa scan – Pan CT to exclude malignancy – 25 (OH) vit D assay
C- stop any calcium supplementation
use non calcium non AL containing po4 binders
avoid calcitriol therapy
use low dialysate calcium in HD
calcium restriction in diet
avoid calcemimetics
B other work up :
lateral spine X-ray for vascular calcification and echocardiography
laboratory: ALP
management plan:
Stop vit D agonist
Stop calcium supplementation or calcium phosphorus binders
low dialysate calcium (1.25-1.5 mmol/l)
use of non calcium based phosphorus binders as sevelamer
A) Appraise the need for calcitriol therapy in this patient.
The principal factor underlying ABD is either:
So calcitriol will suppress PTH
B) Do you suggest any other workup for this patient?
C) Suggest the most likely management plan.
Reversal of PTH suppression — The initial approach to treatment of ABD is to allow PTH secretion to rise.
By:
Monitor treatment response:
Reversal of ABD: increase in PTH and BSAP levels and resolution of hypercalcemia (if present).
A) Appraise the need for calcitriol therapy in this patient.Patient has ESRD on HD with inappropriately low PTH indicating that patient has ABD. I don’t recommend to start on calcitriol as the patient has mildly elevated Ca and High Ph. Calcitriol will suppress PTH further. B) Do you suggest any other work-up for this patient?BTM: BsALP, P1NP
DXA scan with TBS
VFA
Lateral spine X-ray to check for aorta calcification
C) Suggest the most likely management planStop Ca carb if any taken orally
Make sure dietary Ca intake < 2000 mg per day
Decrease Ca in dialysate
Non Ca phosphate binder
Low phosphate diet
Appraise the need for calcitriol therapy in this patient .this patient does not need calcitorial
Do you suggest any other work-up for this patientthis patient need xray ,echo , CT scan for finding any calcifications
Suggest the most likely management plan.low calcium dialysate
low phosphate diet
A-stop
b- BSAP
Lateral abdominal X Ray for any calcification
Echo for calcification valve
c-low ca diet
low ca diyls.
A- likely abd suppressed pth . no need for calcitriol
B- Vitamin D , Bone Makers and Lateral x ray to check calcification
C- observe pth ca/po42- after stopping ca binders , low calcium dialysate stopping alphacalcidol
A)not to use calcitriol in this case
B)check ALP
c ) use low ca dialysate
efficient dialysis ,decrease diet containing phosphate
use non ca containing phosphate binder
A)
Calcitriol should not be used, as it will worsen the condition, although some study found vitD supplements will not aggravate ABD.
B)
C)
We do not need calcitriol therapy in this patient. Ca is 10.12 mg with PTH below the target, which is more optimal around 300 +/- 50; for that reason lowering dialysate calcium to 1.25, replacing or the initiation of non-calcium binding phosphor binders (sevelamer or low dose Lantanum).
No need for calcitriol therapy in this patient
check alkaline phosphatase
dietary restriction of phosphate
low dialyse calcium
non calcium containing phosphate binders
This patient has HIGh CA and PO4 with low PTH which looks like adynamic bone disease
in such area, calcitriol will suppress the PTH more.
Do you suggest any other workup for this patient?Need to check for ALP bone type to be sure of our diagnosis
Suggest the most likely management plan.diet control
use of low CA bath in dialysis
increase the frequency and the length of dialysis
non-Ca phosphate binder along with a low Phosphate diet
A. No need for calcitriol
B. Suggest echo and lat abd X ray
C. Plan ;
diet control
use non calcium containing P binder
stop alpha calcidol and calcimimetics
use low calcium dialysate
Nice explanation dr Ahmed, you can check the model answer below
A) Appraise the need for calcitriol therapy in this patient .
The patient has high normal calcium, high phosphate and low PTH , picture goes with adynamic bone disease , there is no need for calcitriol as it will cause more suppression to PTH and cause more harm.
B) Do you suggest any other work-up for this patient?
BSAP
Lateral abdominal X R for any calcification
Echo for any valvular calcification
C) Suggest the most likely management plan.
Low phosphate diet
Avoid calcimimatics and calcitriol
Use non-calcium phosphate binders
Low calcium dialysate
great answers dr Asmaa, you can check the model answer below
A) this patient have normal calcium , high phosphorus and very slight elevated PTH. The treatment with VDR will be inappropriate because it will rise further his phosphate and calcium level what is not needed in this case and will further suppress his relative low iPTH level.
B) we can measure Bone specific AP, 25 OHVitamin D , we can measure DXA in this case.
C) we will prescribe him non-calcium containing phosphate binders. Dietary consultation and encouraging him to not take above 800-1000 mg calcium daily and to avoid phosphat rich food.
great answers dr Nour, you can check the model answer below with further investigations for cardiovascular calcifications.
A- THIS PATIENT HAS HIGH PHOSPHOROUS , HIGH NORMAL CALCIUM ,AND INADEQUATLY ELEVATED PTH ( SUPRESSED ) SO AVOID VITD AND CALCIUM SUBLEMENTS
B- PATIENT NEEDS FOR OTHER LAB LIKE ALK. PHOSPHAASE , VIT D LEVEL , ALSO NEEDS FOR XRAY , ECHO AND CORONARY CT SCAN MY BE WILL HELP
C- NONCALCIUM PHOSPHATE BINDER , LOW CALCIUM , PROLONGED SESSIONS OF DIALYSIS , DIET CONTROL
Nice answers dr Abdulrahman, you can check the model answer below
A. Calcitriol not need to be given for this patient as he has high phosphorous and low PTH
B. Bsap, lateral x ray of the abdomen for vascular calcification, echocardiography
C. Stop calcimimetic drug or vitamin D analogs, low phosphorous containing diet, non calcium containing phosphate binders, increase dialysis adequacy.
great answers dr Israa, you can check the model answer below. consider also low dialysate calcium
A) Appraise the need for calcitriol therapy in this patient .no need for calcitriol therapy in this patient as he has hyperphosphatemia and low PTH level
B) Do you suggest any other work-up for this patient?i order bone specific alkaline phosphatase
abdominal x ray lateral view
Echo
C) Suggest the most likely management plan.1-dietary phosphate restriction avoid inorganic phosphate diet
2-adequate hemodialysis (high flux ,increase time or frequency of hd )
3=add sevelamer as phosphate binder
4-low calcium dialysate 1.25 mmol
5-avoid any calcium or VDRA or calcimimetics
Great answers dr Emad, you can check the model answer below.
A) Appraise the need for calcitriol therapy in this patient .
No need for adding vit D dueto pt have hyperphosphatemia and upper normal of ca with slight elevation in pth that’s parameters causing depression in pth and induce vascular calcification.
B) Do you suggest any other work-up for this patient?
Serum alkaline phosphatase and bone specific alkaline phosphatase
Echo to exclude cardiac calcification
Xary abdomen in lateral view to detect aortic calcification.
C) Suggest the most likely management plan.
Non ca containing phosphate binders
And low ca diyalisate concentration
Nice answers dr Rabab, you can check the model answer below.
Model answers by the board:
A. Appraise the need for calcitriol therapy in this patient .
This patient most likely has adynamic bone disease (ABD) based on the low PTH and the mild hypercalcemia. The initial approach for treatment of ABD is to allow parathyroid hormone secretion to rise to improve the bone formation rate. This can be achieved by using non-calcium-based phosphate binders; decreasing or stopping active vitamin D analogs; and, for patients on dialysis, possibly by using a low-dialysate calcium concentration according to KDIGO 2017 guidelines (1).
B. Do you suggest any other work-up for this patient?
Lateral abdominal radiograph can be used to detect the presence or absence of vascular calcification, and an echocardiogram can be used to detect the presence or absence of valvular calcification, as reasonable alternatives to computed tomography-based imaging (2C).
Bone-specific alkaline phosphatase can be used to evaluate bone disease because markedly high or low values predict underlying bone turnover (2B), (1).
C. Suggest the most likely management plan.
Restricting dietary phosphate intake and using non-calcium containing phosphate binders as sevelamer. Using calcitriol or oral calcium should be avoided. Suggest using a dialysate calcium concentration between 1.25 and 1.50 mmol/l. These measures help to decrease phosphorus level and guard against more decrease in PTH level that have many hazardous effects on either bone health or cardiovascular calcification.
A) Appraise the need for calcitriol therapy in this patient
This patient is suspected with Adynamic bone disease, Vitamine D analog will further increase both serum calcium and phosphate so no need to add calcitriol for this case
B) Do you suggest any other work-up for this patient?
Bone specific Alkaline phosphatase(BAP)- Vitamin D- Xray-Dexa scan- evaluate for cardiac calcification- check the dialysate calcium concentration.
C) Suggest the most likely management plan.
Correct hyperphosphatemia by using noncalcium phosphate binders and advice low diet phosphate Review dialysate calcium concentration suggest them to use low calcium dialysate
Monitor serum calcium, phosphate and PTH
Great answers dr Mohammed, you can check the model answer above.
Appraise the need for calcitriol therapy in this patient
Do you suggest any other work-up for this patient?
Suggest the most likely management plan: USE low ca dialysate, stop ca based ph binder, ow ca diet, stop vit -Calcimimitic, reviwe the water unit for AL .
Great answers dr Mahmoud, you can check the model answer above.
A) Appraise the need for calcitriol therapy in this patient .
Calcitriol will increase Ca (already normal), will increase PO4 (already high) and will suppress iPTH (not needed)à No need for Calcitriol in this case.
B) Do you suggest any other work-up for this patient?
bALP, lateral spine XR, DEXA scan, VitD levels, ? bone biopsy
C) Suggest the most likely management plan.
low ca dialysate, stop ca based PO4 binder, low ca diet, stop vit D, stop Calcimimitics , check dialysate water for Aluminium.
Nice answers dr Hassan, you can check the model answer above.
Appraise the need for calcitriol therapy in this patient.
Do you suggest any other work-up for this patient?
Suggest the most likely management plan.
Great answers dr Riaan, you can check the model answer above.
A) Appraise the need for calcitriol therapy in this patient .with calcitriol the s.Ca will increase due to increase the absorption of Ca from gut .
so no role to calcitriol in this case.
B) Do you suggest any other work-up for this patient?yes ,
C -Suggest the most likely management plan.
Great answers dr Ashraf, you can check the model answer above.
A) Appraise the need for calcitriol therapy in this patient
We are suspecting ABD
Calcitriol therapy is not preffered for this patient .
The following conditions are contraindicated with this drug:
· sarcoidosis.
· high amount of phosphate in the blood.
· high amount of calcium in the blood.
· excessive amount of vitamin D in the body.
· kidney stones.
· decreased kidney function.
B) Do you suggest any other work-up for this patient?
C/ Suggest the most likely management plan.
Nice answers dr Rania, you can check the model answer above.
the patient has lab evidece of adynamic bone disease, high serum ca and po4, and low PTH. Addition of calcitrol will worse the conditin, increase calcium and phosphorus which will lead to more vascular calcification and suppressing PTH. we should check alkaline phosphatase and serum aluminum. plan of management include :- decreasing serum calcium by holding calcium bsed phosphate binder, decrease calcium in the dialysate
2 – decrease suppression of pth, hold vit d and its analogue or calcimimetics
3- correction of hyperphosphatemia by non calcium, non aluminum phosphate binders
Great answers dr Ahmed, you can check the model answer above.
A) Appraise the need for calcitriol therapy in this patient
Adding calcitriol will increase the absorption of ca and PO4 from the GIT, which will increase the serum ca and PO4, which are already high. also, calcitriol will suppress the PTH more, which is already low and reflect a dynamic bone disease
All this will increase vascular calcification.
Do you suggest any other workup for this patient?
Bone-specific alkaline phosphatase
25-OH VIT D
S.alumonium
Echo, Dexa scan, and CAC score
kt/v
C) Suggest the most likely management planCheck the calcium concentration of the dialysate and make sure it is not more than 1,5
avoid calcium and Vitamin D and vitamin D analog
Search for any source of aluminum, especially in pharmaceuticals and food preparation, and stay away from it.
Re-educate about the importance of avoiding smoking, and decreasing body weight
with close observation of ca, PO4, and PTH
Nice answers dr Ahmed, you can check the model answer above.
A) Appraise the need for calcitriol therapy in this patient .
B) Do you suggest any other work-up for this patient?– Yes,risk factors for ABD
–Evidence of vascular calcifications
–Biomarkers of bone turn over if you have it available
C- Suggest the most likely management plan.-This will largely depends on the risk factors for ABD;
Nice answers dr Ben, you can check the model answer above.
the lab revealed
Hyperphosphatemia
upper border of calcium level
PTH accepted as normal no 2ry HPTH
SO the no need to calcitriol >> may lead to more suppression of PTH
and Hyper calcemia
Start non calcium phosphate binder
management plan
bone assessment to rule out adynamic bone disease
x-ray and DEXA , renal biopsy
and follow up ca , pi , vit D and PTH
Nice answers dr Elsayed, you can check the model answer above.
A- there is no need for calcitriol therapy for this patient as he has high normal calcium and increased po4 level with oversuppressed PTH which will be exaggerated by Vit D therapy
B- Dexa scan – Pan CT to exclude malignancy – 25 (OH) vit D assay
C- stop any calcium supplementation
use non calcium non AL containing po4 binders
avoid calcitriol therapy
use low dialysate calcium in HD
calcium restriction in diet
avoid calcemimetics
I do not think there is a need for Pan CT to exclude malignancy
A) Appraise the need for calcitriol therapy in this patient
B) Do you suggest any other work-up for this patient?
C) Suggest the most likely management plan.
Nice answers dr Ibrahim, you can check the model answer above.