A 32-year-old man presents for routine review. He has been on hemodialysis for five years. Hyperphosphatemia had been noticed 9 months previously and the patient had been reviewed by the dieticians at that time. However, the patient refused to follow a phosphate restricted diet and there had been persistent non-compliance to medications.
Test
Value
S. Creatinine
3.9 mg/dL
S. corrected Calcium
8.00 mg/dL
S. Phosphorus
10.2 mg/dL
iPTH
1030 pg/mL
25 (OH) D
14.9 ng/mL
A. Interpret the above laboratory investigations.
B. Do you recommend surgical parathyroidectomy at this stage?
37 Comments
Radwa Ellisy
A. Interpret the above laboratory investigations.
This patient has hypocalcemia and hyperphosphatemia, low vit D and hyperparathyroidism, this is a picture of secondary hyperparathyroidism
B. Do you recommend surgical parathyroidectomy at this stage?
No, first control by diet restriction of phosphorus and medical treatment by
– paricalcitol as it is potent and low effect on phosphorus
– With native vit D to increase the level of vit D
– Besides phosphorus binder calcium based or non calcium based as sevelamer
ESRD caues hyperphosphatemia and vitamin D deficiency leading to secondary hyperparathyroidism due to hypocalcemia
B. Do you recommend surgical parathyroidectomy at this stage?
I don’t recommend surgical options at this point. The patient must improve his compliance with medical therapy; phosphate-restricted diet, sevelamer, and vitamin D analog. When the Ca level improves, we might add cinacalcet or etelcalcitide IV.
. Interpret the above laboratory investigations.hypocalcemia, hyperphosphatemia and secondary hyperparathyroidism, hypovitaminosis vit d Do you recommend surgical parathyroidectomy at this stage?parathyroidectomy is recommended in refractory hyperparathyroidism and i agree in this case because of severely elevated of PTH
A. Interpret the above laboratory investigations.CKD 5D with hypocalcemia, hyperphosphatemia and secondary hyperparathyroidism with vitamin D deficiency.because of persistent non-compliance to medications.
B. Do you recommend surgical parathyroidectomy at this stage?I suggest a medical treatment that includes phosphorous restrictions, Sevalamer , vitamin D analogue, cinacalcit, increase dialysis adequacy
If there is no improvement after three months, consider surgical ttt.
Should focus on increasing patient compliance.
Lab investigations show mild hypocalcemia, hyperphosphatemia, secondary hyperparathyroidism and vitamin d deficiency
I recommend trial of medical treatment
repleate vitamin d
calcium containing phosphate binder plus calcimimitics
follow up if no response after 3 months consider surgical ttt
Thank you dear all for your contributions. Here the answer of this part:
A. Interpret the above laboratory investigations.
The patient presented with severe high PTH level according to KDIGO 2017 guidelines (2-9 folds of upper normal limit). Hyperphosphatemia and hyperparathyroidism are persistent because of non compliance to management plans. Hypovitaminosis D is another possible cause of hypocalcemia and hyperparathyroidism .
B. Do you recommend surgical parathyroidectomy at this stage? Parathyroidectomy should be considered in patients with CKD stage 5D who fail medical therapy for secondary hyperparathyroidism or to those who develop tertiary hyperparathyroidism. Efforts should be focused on improving patients compliance.
A. PATIENT AT CKD5 D WITH HYPERPARATHYROIEDISM WITH HYPOCALCEMIA AND HYPERPHOSPHATEMIA AS WELL ALSO HE HAS LOW VIT D
B. MOSTLY HE WILL NEEDS FOR SURICAL TREATMENT BUT IT WILL BE WORTHY AGAIN TO TRY WITH HIM MEDICAL TREATMENT INCLUDING CALCLMEMETICS , PHOSPHATE BINDER , VIT D AND FREQUENT DIALYSIS WITH STRICT DIET CONTROL
A. Interpret the above laboratory investigations.CKD 5D with hypocalcemia, hyperphosphatemia and secondary hyperparathyroidism with vitamin D deficiency. B. Do you recommend surgical parathyroidectomy at this stage?No, first we must make sure from his compliance with strict dietary restriction of phosphate along with medical treatment in the form of phosphate binders and cinacalcet . Surgical intervention indicated only if medical treatment failed and in tertiary HPT.
A. He has low corrected calcium, sever hyperphosphatemia, hyperparathyroidism and low vitamin D storage
B. No, medical treatment include
Phosphorous restrictions, non phosphate containing binders, vitamin D analogue, cinacalcit, increase dialysis adequacy
Interpret the above laboratory investigations.
very high level of PO4,
low Ca,
low Vit-D,
high iPTH.
2ndy hyperparathyroidism. Do you recommend surgical parathyroidectomy at this stage?
no indication of parathyroidectomy
control the PO4 with a sevelamer
if no response, add vitamin D with cinacalcet.
A. Hypocalcemia, severe hyperphosphatemia, vitamin D deficiency, secondary hyperparathyroidism.
B. I recommand medical treatment . A parathyreoidectomy may aggravate the existing hypocalcemia and vitamin d deficency so i don’t recommend it to a non compliant patient.
A. Interpret the above laboratory investigations.
CKD5-HD, Hyperphosphatemia, High level of PTH and Low level of vitamin D
B. Do you recommend surgical parathyroidectomy at this stage?
No, I will not recommend now for parathyroidectomy, i will suggest him to control the phosphate by using phosphate binders and control the low levels of vitamin D by giving vitamin D analogs, monitor the Ca, phosphate and PTH.
A. Interpret the above laboratory investigations.
ESRD with low normal ca and high po4 markedly elevated pth mostly secondary hyperparathyroidism and low level of vit d
B. Do you recommend surgical parathyroidectomy at this stage?
Not yet we should have trial with calcimimitic
A. Interpret the above laboratory investigations.
As is typical of SHPT, the patient has low calcium, high PO4, and high PTH; he also has a vitamin D deficiency.
B. Do you recommend surgical parathyroidectomy at this stage? No, I don’t recommend surgery at this stage. There is still a place for medical therapy.
A. Interpret the above laboratory investigations.CKD 5D
mild hypocalcemia and severe hyperphostameia
severe SHPT ,hypovitaminosis D
============================ B. Do you recommend surgical parathyroidectomy at this stage?i do not recommend surgery at this stage
before surgery
1-correct hyperphosphatemia by diet and calcium based phosphate binder
2-add cinacalcet
3-correct hypovitaminosis D after correction of phosphate
This patient has severe hyperphosphataemia and SHPTH, along with mild hypocalcemia
and Vit D deficiency
this patient needs to be started on Ca base phosphate binder and needs to control his diet
cinacalcet is the drug of choice here, but be careful of Ca level as it may cause hypocalcemia.
At this stage will not add Vit d
always will start with medical treatment.
Do you recommend surgical parathyroidectomy at this stage?
No I don’t recommend surgical intervention at this stage
A. Interpret the above laboratory investigations. ESRD on Regular HD , non compliant to diet , mild hypocalcemia , sever hyperphosphatemia , secondary hyperparathyroidism and Vitamin D deficiency. B. Do you recommend surgical parathyroidectomy at this stage? Before thinking in parathyroidectomy we will start with
Health education about importance of compliance to medications and diet
start with non calcium containing P binder
after starting control of P and when achieving acceptable CA P product , we can use also calcium containing P binder which will help to raise S calcium so we can start cinacalcet to control High PTH .
Non-compliance is very frequent in young dialysis patients. Very high phosphate and very high iPTH secondary to hyperphosphatemia and end-stage disease interfering with both alpha hydroxylation and vitamin d itself, leading to low vitamin D and active vitamin d as in our scenario.
PLAN should be putting effort and more explanation to patients about the importance of phosphate (though each centre has 1 or 2 resistant patients like this). Temporarily lowering is not useful anyway.. elongation of dialysis sessions and drugs are not enough without a strict diet. (hidden sources of phosphorus are important)
Practically according to health insurance policies, I will use aluminium hydroxide just for 1-2 weeks, give Lantanium (if affordable or covered), and add calcium acetate or carbonate later (after phosphorous <6.5). I will later add cinacalcet after the elevation of calcium together with iv paricalcitol (lower hyperphosphatemia!)
** Lantanum is available as a powder, but we can give 1000 mg three times with meals (or sevelamer 800 mg (5 tablets with each meal) .. in case of gastric disturbance, we can titrate the dose
lab revealed mild Hypocalcemia Hyper phosphatemia 2ry HPT vit. D deficiency THE PLAN start conservative treatment no need surgical parathyroidectomy at this stage 1- Diet control 2-ca -containing phophorus binding 3- calcitriol tab 3- vit-D suplement follow up monthly ca , pi , pth , vit.d
A. Interpret the above laboratory investigations.The lab revealed a very high level of PO4, low Ca, low Vit-D, and high iPTH. this lab indicates 2ndy hyperparathyroidism.
B. Do you recommend surgical parathyroidectomy at this stage?There is no indication of parathyroidectomy at this stage. need to control the PO4 with a sevelamer
and if there is no response, add vitamin D with cinacalcet as the next step.
the patient has hyperphosphatemia, hypocalcemia, and vit d deficiency causing uncontrolled uncontrolled hyperparathyroidism, although we do not know muscle bulk of the patient or ktv but serum creatinine is accepted, mostly is not under dialyzed.
most likely the patient has high turnover bone disease as PTH > 600, but it is so early to go to parathyroidectoy which carries high risk of low bone turn over
A. Interpret the above laboratory investigations.-3 KEY findings:
ESKD, from the history and Cr = 3.9
sHPT evidenced by hypocalcemia, hyperphosphatemia, & very high iPTH
Vitamin D deficiency
B. Do you recommend surgical parathyroidectomy at this stage?
No, he has vitamin D deficiency, and this has to be treated first. Treatment of vitamin D may help to control high PTH together with calcimimetics. We also need to address the issue of severe hyperphosphatemia which is an important driver of sHPT before any surgical intervention.
Parathyroidectomy should be considered in patients with CKD stage 5D who fail medical therapy for secondary hyperparathyroidism or to those who develop tertiary hyperparathyroidism. Efforts should be focused on improving patients compliance.
Parathyroidectomy should be considered in patients with CKD stage 5D who fail medical therapy for secondary hyperparathyroidism or to those who develop tertiary hyperparathyroidism. Efforts should be focused on improving patients compliance
A- A case with renal impairment , hypocalcemia, hyperphosphatemia , secondary hyperparathyroidism with Vit D deficiency.
B- As Vit D analouges cannot be used because of increased po4 levels and cinacalcet may worsen hypocalcemia , surgical option may be discussed in this situation.
Parathyroidectomy should be considered in patients with CKD stage 5D who fail medical therapy for secondary hyperparathyroidism or to those who develop tertiary hyperparathyroidism. Efforts should be focused on improving patients compliance
A. Interpret the above laboratory investigations.
This patient has hypocalcemia and hyperphosphatemia, low vit D and hyperparathyroidism, this is a picture of secondary hyperparathyroidism
B. Do you recommend surgical parathyroidectomy at this stage?
No, first control by diet restriction of phosphorus and medical treatment by
– paricalcitol as it is potent and low effect on phosphorus
– With native vit D to increase the level of vit D
– Besides phosphorus binder calcium based or non calcium based as sevelamer
A. Interpret the above laboratory investigations.
All attributed to the pathogenesis of SHPT.
B. Do you recommend surgical parathyroidectomy at this stage?
A- lack of compliance and hypovitaminosis causing causing secondary hyperparathyroidssim.
B if unable to address lack of compliance then consider surgery
A. Interpret the above laboratory investigations.
ESRD caues hyperphosphatemia and vitamin D deficiency leading to secondary hyperparathyroidism due to hypocalcemia
B. Do you recommend surgical parathyroidectomy at this stage?
I don’t recommend surgical options at this point. The patient must improve his compliance with medical therapy; phosphate-restricted diet, sevelamer, and vitamin D analog. When the Ca level improves, we might add cinacalcet or etelcalcitide IV.
. Interpret the above laboratory investigations.hypocalcemia, hyperphosphatemia and secondary hyperparathyroidism, hypovitaminosis vit d
Do you recommend surgical parathyroidectomy at this stage?parathyroidectomy is recommended in refractory hyperparathyroidism and i agree in this case because of severely elevated of PTH
A-hypocalcemia,+hyperphosphatemia and secondary hyperparathyroidism with vitamin D deficiency.
b- yes
A. Interpret the above laboratory investigations.CKD 5D with hypocalcemia, hyperphosphatemia and secondary hyperparathyroidism with vitamin D deficiency.because of persistent non-compliance to medications.
B. Do you recommend surgical parathyroidectomy at this stage?I suggest a medical treatment that includes phosphorous restrictions, Sevalamer , vitamin D analogue, cinacalcit, increase dialysis adequacy
If there is no improvement after three months, consider surgical ttt.
Should focus on increasing patient compliance.
Lab investigations show mild hypocalcemia, hyperphosphatemia, secondary hyperparathyroidism and vitamin d deficiency
I recommend trial of medical treatment
repleate vitamin d
calcium containing phosphate binder plus calcimimitics
follow up if no response after 3 months consider surgical ttt
Thank you dear all for your contributions.
Here the answer of this part:
A. Interpret the above laboratory investigations.
The patient presented with severe high PTH level according to KDIGO 2017 guidelines (2-9 folds of upper normal limit). Hyperphosphatemia and hyperparathyroidism are persistent because of non compliance to management plans. Hypovitaminosis D is another possible cause of hypocalcemia and hyperparathyroidism .
B. Do you recommend surgical parathyroidectomy at this stage?
Parathyroidectomy should be considered in patients with CKD stage 5D who fail medical therapy for secondary hyperparathyroidism or to those who develop tertiary hyperparathyroidism. Efforts should be focused on improving patients compliance.
A. PATIENT AT CKD5 D WITH HYPERPARATHYROIEDISM WITH HYPOCALCEMIA AND HYPERPHOSPHATEMIA AS WELL ALSO HE HAS LOW VIT D
B. MOSTLY HE WILL NEEDS FOR SURICAL TREATMENT BUT IT WILL BE WORTHY AGAIN TO TRY WITH HIM MEDICAL TREATMENT INCLUDING CALCLMEMETICS , PHOSPHATE BINDER , VIT D AND FREQUENT DIALYSIS WITH STRICT DIET CONTROL
A. Interpret the above laboratory investigations.CKD 5D with hypocalcemia, hyperphosphatemia and secondary hyperparathyroidism with vitamin D deficiency.
B. Do you recommend surgical parathyroidectomy at this stage?No, first we must make sure from his compliance with strict dietary restriction of phosphate along with medical treatment in the form of phosphate binders and cinacalcet . Surgical intervention indicated only if medical treatment failed and in tertiary HPT.
A. He has low corrected calcium, sever hyperphosphatemia, hyperparathyroidism and low vitamin D storage
B. No, medical treatment include
Phosphorous restrictions, non phosphate containing binders, vitamin D analogue, cinacalcit, increase dialysis adequacy
Interpret the above laboratory investigations.
very high level of PO4,
low Ca,
low Vit-D,
high iPTH.
2ndy hyperparathyroidism.
Do you recommend surgical parathyroidectomy at this stage?
no indication of parathyroidectomy
control the PO4 with a sevelamer
if no response, add vitamin D with cinacalcet.
A. Hypocalcemia, severe hyperphosphatemia, vitamin D deficiency, secondary hyperparathyroidism.
B. I recommand medical treatment . A parathyreoidectomy may aggravate the existing hypocalcemia and vitamin d deficency so i don’t recommend it to a non compliant patient.
The above labs show
Severe hyperphosphatemia, FGF23 activation, reduce active vitD, hypocalcemia and activation of PTH.
Surgical parathyroidectomy after the failure of medical treatment;
A. Interpret the above laboratory investigations.
B. Do you recommend surgical parathyroidectomy at this stage?
For question B, I would also add Vit D supplementation
A. Interpret the above laboratory investigations.
CKD5-HD, Hyperphosphatemia, High level of PTH and Low level of vitamin D
B. Do you recommend surgical parathyroidectomy at this stage?
No, I will not recommend now for parathyroidectomy, i will suggest him to control the phosphate by using phosphate binders and control the low levels of vitamin D by giving vitamin D analogs, monitor the Ca, phosphate and PTH.
A. Interpret the above laboratory investigations.
ESRD with low normal ca and high po4 markedly elevated pth mostly secondary hyperparathyroidism and low level of vit d
B. Do you recommend surgical parathyroidectomy at this stage?
Not yet we should have trial with calcimimitic
A. Interpret the above laboratory investigations.
As is typical of SHPT, the patient has low calcium, high PO4, and high PTH; he also has a vitamin D deficiency.
B. Do you recommend surgical parathyroidectomy at this stage?
No, I don’t recommend surgery at this stage. There is still a place for medical therapy.
A. Interpret the above laboratory investigations.CKD 5D
mild hypocalcemia and severe hyperphostameia
severe SHPT ,hypovitaminosis D
============================
B. Do you recommend surgical parathyroidectomy at this stage?i do not recommend surgery at this stage
before surgery
1-correct hyperphosphatemia by diet and calcium based phosphate binder
2-add cinacalcet
3-correct hypovitaminosis D after correction of phosphate
This patient has severe hyperphosphataemia and SHPTH, along with mild hypocalcemia
and Vit D deficiency
this patient needs to be started on Ca base phosphate binder and needs to control his diet
cinacalcet is the drug of choice here, but be careful of Ca level as it may cause hypocalcemia.
At this stage will not add Vit d
always will start with medical treatment.
Do you recommend surgical parathyroidectomy at this stage?
No I don’t recommend surgical intervention at this stage
A. Interpret the above laboratory investigations. ESRD on Regular HD , non compliant to diet , mild hypocalcemia , sever hyperphosphatemia , secondary hyperparathyroidism and Vitamin D deficiency.
B. Do you recommend surgical parathyroidectomy at this stage? Before thinking in parathyroidectomy we will start with
Non-compliance is very frequent in young dialysis patients. Very high phosphate and very high iPTH secondary to hyperphosphatemia and end-stage disease interfering with both alpha hydroxylation and vitamin d itself, leading to low vitamin D and active vitamin d as in our scenario.
PLAN should be putting effort and more explanation to patients about the importance of phosphate (though each centre has 1 or 2 resistant patients like this). Temporarily lowering is not useful anyway.. elongation of dialysis sessions and drugs are not enough without a strict diet. (hidden sources of phosphorus are important)
Practically according to health insurance policies, I will use aluminium hydroxide just for 1-2 weeks, give Lantanium (if affordable or covered), and add calcium acetate or carbonate later (after phosphorous <6.5). I will later add cinacalcet after the elevation of calcium together with iv paricalcitol (lower hyperphosphatemia!)
** Lantanum is available as a powder, but we can give 1000 mg three times with meals (or sevelamer 800 mg (5 tablets with each meal) .. in case of gastric disturbance, we can titrate the dose
lab revealed
mild Hypocalcemia
Hyper phosphatemia
2ry HPT
vit. D deficiency
THE PLAN
start conservative treatment no need surgical parathyroidectomy at this stage
1- Diet control
2-ca -containing phophorus binding
3- calcitriol tab
3- vit-D suplement
follow up monthly ca , pi , pth , vit.d
I agree with you but calcitriol should be postponed until correction of serum phosphorus. Cinacalcet has a beneficial role in this case.
A. Interpret the above laboratory investigations.The lab revealed a very high level of PO4, low Ca, low Vit-D, and high iPTH. this lab indicates 2ndy hyperparathyroidism.
B. Do you recommend surgical parathyroidectomy at this stage?There is no indication of parathyroidectomy at this stage. need to control the PO4 with a sevelamer
and if there is no response, add vitamin D with cinacalcet as the next step.
the patient has hyperphosphatemia, hypocalcemia, and vit d deficiency causing uncontrolled uncontrolled hyperparathyroidism, although we do not know muscle bulk of the patient or ktv but serum creatinine is accepted, mostly is not under dialyzed.
most likely the patient has high turnover bone disease as PTH > 600, but it is so early to go to parathyroidectoy which carries high risk of low bone turn over
A. Interpret the above laboratory investigations.-3 KEY findings:
B. Do you recommend surgical parathyroidectomy at this stage?
A. Interpret the above laboratory investigations.
B. Do you recommend surgical parathyroidectomy at this stage?
Parathyroidectomy should be considered in patients with CKD stage 5D who fail medical therapy for secondary hyperparathyroidism or to those who develop tertiary hyperparathyroidism. Efforts should be focused on improving patients compliance.
A)ESRD with hypocalcemia ,sever hyperphosphatemia and low VD case of SHPT
B)No surgical intervention isn’t recommended at this stage
Parathyroidectomy should be considered in patients with CKD stage 5D who fail medical therapy for secondary hyperparathyroidism or to those who develop tertiary hyperparathyroidism. Efforts should be focused on improving patients compliance
A. Interpret the above laboratory investigations.
B. Do you recommend surgical parathyroidectomy at this stage?
Thanks dr Ibrahim. the role of cinacalcet in controlling hyperparathyroidism is very important also.
A- A case with renal impairment , hypocalcemia, hyperphosphatemia , secondary hyperparathyroidism with Vit D deficiency.
B- As Vit D analouges cannot be used because of increased po4 levels and cinacalcet may worsen hypocalcemia , surgical option may be discussed in this situation.
Parathyroidectomy should be considered in patients with CKD stage 5D who fail medical therapy for secondary hyperparathyroidism or to those who develop tertiary hyperparathyroidism. Efforts should be focused on improving patients compliance