Scenario 1 - Part 2:
Unfortunately this patient was malmanaged, he has been prescribed calcium containing phosphate binders and calcitriol. Three months later, the following blood results has been obtained
Test |
Value |
S. Creatinine |
4.8 mg/dL |
S. Corrected Calcium |
10.65 mg/dL |
S. Phosphorus |
5.2 mg/dL |
iPTH |
44 pg/mL |
An echocardiography has been performed during a routine visit to the cardiology clinic and revealed extensive mitral and aortic valve calcification
D) Appraise the above-mentioned plan of management.
F) Discuss the cardiovascular outcome in such patient.
Three months later, the patient presented to the emergency department with severe lower back pain after he slipped in the kitchen. X-ray of the lumbar spine showed L2 compression fracture
F) How do you like to evaluate his bone strength?
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D) the ideal management is to allow the parathyroid to rise and avoid vit d analogs and calcium-based phosphorus binders to prevent over suppression.
F) adynamic bone disease is associated with increased cardiovascular complications because of increased vascualar and valvular calcificaation
F) Bone strength could be evaluated by DEXA scan, bone-specific ALP, bone biopsy
D) Appraise the above-mentioned plan of management
The initial approach to the treatment of ABD is to allow PTH secretion to RISE, while he has been prescribed calcium containing phosphate binders and calcitriol, which result in further suppression of PTH.
One randomized, prospective trial has suggested that the use of non-calcium-based binders may increase the bone formation rate. Among 68 HD patients randomly assigned to receive sevelamer or calcium carbonate, although there were no changes in bone turnover between groups at one year, the bone formation rate per bone surface increased from baseline in the sevelamer group but not in the calcium carbonate group.
(Ferreira A et al, J Am Soc Nephrol. 2008;19(2):405. Epub 2008 Jan 16).
F) Discuss the cardiovascular outcome in such a patient.
F) How do you like to evaluate his bone strength?
D) Appraise the above-mentioned plan of management.Patient was mismanaged by adding calcitriol and ca containing phosphate binders that led to worsen his Ca level and suppressed PTH.
F) Discuss the cardiovascular outcome in such patient.ESRD patient has a higher risk for cardiovascular calcification, and adding Calcitriol and Ca phosphate binders in patients who has high Ca and PH levels, would definitely worsened vascular calcification.
F) How do you like to evaluate his bone strengthDXA scan with TBS
Bone biopsy
D.Appraise the above-mentioned plan of management.this management had worsened the elevation of calcium.
F.this has increased the cardiovascular calcification and mortality.
dexa scan
mri
biopsy
A-adynmic bone dis and worse with high ca
b-incrase mortality
c-dexa scan and biopsy
D- ABD and continuning calcium based therapy will lead to complication
F- increased cardiovascular mortality and mortality due to calcification of vessels . Bone markers , dexa and bone biopsy
A; This patient mostly in adynamic bone and her bone will not be able to buffer excess calcium which will aggravate vascular calcification.
B; Increased risk of vascular calcification and increased mortality risk .
C; DEXA scan and bone biopsy .
D)unfortunately ca loaded worsen ABD
E)increase CV calcification and increase mortality
F) BSAP
PET Ct scan
bone biopsy
D)
E)
This patient has vascular calcification with increased CaXPi product; with increased mortality, 5-20 fold higher in HD patients compared to the general population.
With the extent of vascular calcification and the site of calcification is the predictor of cardiovascular and al cause mortality.
F)
D) Appraise the above-mentioned plan of management.
F) Discuss the cardiovascular outcome in such patient.This patient’s outcome is very poor. So increase risk of cardiovascular calcification and mortality.
F) How do you like to evaluate his bone strength?
The MRI shows a compression fracture which can be due to dynamic bone disease, the problem in bone formation that resulted from supersession of the PTH. Evaluation of bone markers, DEXA, and QCT can be helpful where the standard bone biopsy is not available. The patient is expected to have many vascular calcifications leading to poor outcomes.
Although calcitriol and calcium containing phosphate binders reduce phosphorus, they increase calcium load and suppress pth level (low turn over bone disease) so it was bad choice
ABD reduces bone capacity to buffer calcium and ability to handle extra calcium load. so increase risk of cardiovascular calcification and mortality.
Estimation of trabecular bone score by DXA scan
HR-pQCT
PET scan
MRI
Bone biopsy
The approach of giving more Ca and calcitriol will aggravate this patient’s ABD and will lead to further suppression of PTH and increase her CV risk, as we can see this patient has severe mitral and ortic calcification in her recent Echo .
Discuss the cardiovascular outcome in such a patient.
this patient’s outcome is very poor
How do you like to evaluate his bone strength?
By DEXA scan BSAP and bone biopsy.
D) Appraise the above-mentioned plan of management.
The pt not needed to take calciterol or ca containing phosphate binders dueto hypercalcimia and more suppression of prh
E) Discuss the cardiovascular outcome in such patient.
Due to presence of adynamic bone disease with hypercalcimia and phosphorus upper normal and taken vit d increase vascular and valvular calcification so poor out come
F) How do you like to evaluate his bone strength?
Lab by bone specific alkaline phosphatase essential to detect bone turn over and radiological by dexa scan lastly and most accurate bone biopsy
D) Appraise the above-mentioned plan of management.
This is wrong plan as the use of calcium based phosphate binders and calcitriol will cause over suppression of PTH which is already in the lower side , and agrevate adynamic bone status with it’s deleterious outcome.
F) Discuss the cardiovascular outcome in such patient.
Cardiovascular calcification associated with poor survival rate and poor outcome.
F) How do you like to evaluate his bone strength?
By DEXA scan BSAP and bone biopsy.
D. The above mentioned plan is not correct due to high calcium load and oversuppression of iPTH on this dialysis patient leading to increased risk of cardiovascular calcification and leading to low turnover bone disease.
E. The cardiovascular outcome of this patient on current treatment ist poor because of the current treatment increasing the risk of calcification in tissue and vessels including CAC. The patient has obviously low turnover bone disease what lead to compression fracutre on L2.
F. Low turnover bone disease with decreased osteoblast and osteoclast populatoin , normal mineralisation and low volume what make them fragile and more prone to low stress fracture because of inability to repair themself.
Measuring his bAP and TRAP , DXA scan.
low AP under 200 and with this low iPTH will have high specifity and sensitivity to ABD.
PATIENT HAD MORE SUPRESSED PTH ,AND ALSO VALVE CALCIFICTION MOSTLIKLY HE HAS VASCULAR CALCIFICATION , NEEDS FOR BONE BIOPSY AS WELL NEEDS FOR ACTIVE ORTHOPEDIC AND CARDILOGY MANAGMENT
CARDIOVASCULAR OUTCOME IS POOR , HIGH MORTALITY RISK
D. Oversuppresion of pth due to use of calcitriol and calcium and evidence of cardio-vascular calcification
E. He has CV calcification which is associated with increase risk of mortality
F. Evaluate the patient by the DXA scan and bone biopsy
D) Appraise the above-mentioned plan of management.patient has low PTH according to target due to oversuppression by calcitriol
and increase calcium due to calcium supply
F) Discuss the cardiovascular outcome in such patientpatient at high risk of cardiovascular disease due to cardiovascular calcification
F) How do you like to evaluate his bone strength?patient has fragility fracture
X-ray of the lumbar spine showed L2 compression fractureneed to do DXA scan
Model answers by the board:
D. Appraise the above-mentioned plan of management
The patient has PTH level below the target, so it is not reasonable to use calcitriol or calcium containing phosphate binder to avoid the risk of oversuppression of PTH level and the risk of adynamic bone disease and cardiovascular calcification. The patient has mild hypercalcemia and extensive cardiovascular calcifications, so calcium containing phosphate binders should be avoided. In normal circumstances, 99% of calcium inside our body goes to the skeleton. This patient’s bone is probably hypoactive, so any extra calcium is not going to be utilized by the bone and then mobilizes from the intravascular space to the soft tissue inducing significant cardiovascular calcifications.
E. Discuss the cardiovascular outcome in such patient.
Patients with adynamic bone disease (low PTH level) are at high risk of valvular and vascular calcifications. Calcium overload is associated with arterial calcification, which is associated with arterial stiffening especially aorta and coronary arteries, consequently, increasing cardiovascular morbidity and mortality. Plain X-ray of the hand and pelvis is used to assess arterial calcification using the Adragao score. Another method for assessing calcification is the Kauppila score that evaluates the abdominal aorta. Coronary artery calcification (CAC) is assessed by an Agatston score.
F. How do you like to evaluate his bone strength?
Dual-energy x-ray absorptiometry [DXA] T-score ≤-2.5) and bone biopsy are used to assess bone health. Bone-specific alkaline phosphatase (BSAP) may be used to evaluate bone disease, because high or low values predict underlying bone turnover. BSAP has several advantages compared to iPTH mea-surement. It does not accumulate with progressive loss of glomerular filtration rate, has lower biological variation, exhibits better agreement across methods of mea-surement, is stable ex vivo and does not require strict preanalytical handling procedure
D) Appraise the above-mentioned plan of management.
The patient’s situation got worsen as PTH suppressed more aggravating Adynamic Bone Disease
F) Discuss the cardiovascular outcome in such patient.
according to this patient’s condition cardiovascular mortality is high since high calcium and phosphate with PTH changes will worsen his outcome
F) How do you like to evaluate his bone strength?
Dexa scan
Quantitative Computed Tomography (QCT)
D) Appraise the above-mentioned plan of management.
The management he received has unfortunately kept him in positive Ca balance and has caused extraosseous Ca deposition, including heart valve leaflets, and has pushed his iPTH to lower side giving him ABD
E) Discuss the cardiovascular outcome in such patient.
This patient now has traditional risk factor (valves) and non-traditional risk factors owing to his ESKD.
F) How do you like to evaluate his bone strength?
DEXA and lateral spine XR
Appraise the abovementioned management plan.
Cardiovascular outcome.
Evaluate the bone strength.
D) Appraise the above-mentioned plan of management.
incorrect managment plan
E Discuss the cardiovascular outcome in such patient.increase morbidity and mortality due to vavular and vascular calcification .
F – How do you like to evaluate his bone strength?bone biopsy.
MRI
DXA
qCT
the patient was managed by lines of ttt that aggrevate his condition PTH became more suppresed,serum calcium and phosphorus became more high. high calcium and phosphorus will worsen vascular calcification and low PTH is assosciated with high CVS mortality rate. evaluation of stength: 1- DXA scan and quantitative computed tomography, but they have several limitations in CKD patients due to soft tissue calcification and osteoarthiritis 2- high resolution peripheral quantitative computed tomography: can assess microarchitecture accurately 3-positron emission tomography: fluoride activity can reflect bone formation, bone cells activity. 4- MRI : assess microarchitecture. bone biopsy is the gold standard test for assessment
D) Appraise the above-mentioned plan of management.When his hypercalcemia, iPTH, and widespread calcification all continue to deteriorate, it’s easy to see how his positive calcium balance will eventually lead to his death from cardiovascular disease and other causes.
Discuss the cardiovascular outcome in such a patient.In prospective HD research, Barreto et al. found that LBT status independently predicted CAC advancement. CAC reduced bone growth in 207 HD patients. In LBT patients, activation frequency and bone formation rate was negatively associated with CAC scores.
F) How do you like to evaluate his bone strength?Dual-Energy X-ray Absorptiometry (DXA) Scan and Quantitative Computed Tomography (QCT)
High-Resolution Peripheral Quantitative Computed Tomography (HR-pQCT)
Positron Emission Tomography (PET) Scan
Magnetic-Resonance Imaging (MRI)
bone biopsy
Nice answers dr Weam, you can check the model answer above.
D) Appraise the above-mentioned plan of management.
E) Discuss the cardiovascular outcome in such patient.
F) How do you like to evaluate his bone strength?
Nice answers dr Ben, you can check the model answer above.
unfortunately pt. complicated from medication treatment
Hypercalcemia
still Hyperphosphatemia
Suppression of PTH
Complicated >> valvular calcification and the already old MI and CABG
so worsening the condition and outcome
Also pt, complicated bone disease >>>>> osteoporosis
Adynamic bone disease >>>> risk of bone fracture
Nice answers dr Elsayed, you can check the model answer above.
D- this is malpractice as non calcium containing po4 binders will be more suitable in yhis patient and use of calcitriol will worsen the PTH suppression as compared to previous lab results
E- this patient has a great risk of cardiovascular morbidity and mortality due to vascular and valvular calcification as well as the already present past Hx of MI and CABG as mentioned before which adds to this risk odds
F- there is increased translucency of vertebral body , osteomalacia and compression in intervertebral discs
Nice answers dr Mark, you can check the model answer above.
F) How do you like to evaluate his bone strength?
D) Appraise the above-mentioned plan of management.
F) Discuss the cardiovascular outcome in such patient.
Nice answers dr Ibrahim, you can check the model answer above.