Scenario 1 - Part 2:

The patient’s compliance has been improved after several attempts to convince him with the importance of adherence to his medications. He has been started on cinacalcet, calcitriol, and the dialysate calcium level is maintained at 1.25mmol/L. The patient’s lab one month later showed.

Test

Value

S. Creatinine

3.7 mg/dL

S. corrected Calcium 

8.6 mg/dL

S.Phosphorus

11.3 mg/dL

iPTH

730 pg/mL


C. To what extent do you agree with the above plan of management?

D. Discuss the potential role of dialysate calcium in patients with CKD-MBD.

36 Comments

  • Radwa Ellisy


    I don’t agree with some points

    • calcitriol use: as it increases phosphorus as shown here, better use paricalcitol
    • calcimimetics also could decrease the calcium, especially in borderline patients with calcium 8 as our index case
    • Also, dialysate calcium is better to be 1.5 mmol/l
    • adding phosphorus binders either calcium-based or non calcium- based sevelamer.

    according to KDIGO guidelines dialysate calcium between 1.25-1.5 mmol/l

  • Amna Kununa


    C. To what extent do you agree with the above plan of management?
    Agre,e except for calcitriol

    • All patients with persistently elevated or progressively rising PTH for modifiable risk factors, including hyperphosphatemia, high phosphate intake, and vitamin D deficiency.
    • We do not use calcitriol if the serum phosphate is above the normal range.
    • Calcitriol increases:

    renal NPT2a expression and phosphate reabsorption
    intestinal NPT2b expression and phosphate absorption.

    calcitriol: positive effect on intestinal and renal phosphate absorptions

    D. Discuss the potential role of dialysate calcium in patients with CKD-MBD.
    In patients with CKD G5D, we suggest using a dialysate calcium concentration between 1.25 and 1.50 mmol/l (2.5 and 3.0 mEq/l) (2C) as per KDIGO.

  • Muhammad Soobadar


    C calcitriol can make phosphate worse thererfore avoid
    D kdigo recommend calcium dialysate 1.25-1.50 mmol/l

  • Asma Aljaberi



    C. To what extent do you agree with the above plan of management?
    I agree with the above management; calcitriol, increase Ca in dialysate which helps in improving Ca level, and as a consequence lowered PTH level along with cinacalcet.
    Once Ca level improves, I would stop Calcitriol to avoid worsening of Phosphate level.

    D. Discuss the potential role of dialysate calcium in patients with CKD-MBD.
    The recommended dose of Ca in dialysate is 1.25-1.5 mmol/L, which improves CKD-MBD. I personally use a bit higher dose post anti-resorptive agents for one week to avoid risk of hypocalcemia induced by drug.

  • Mohamed Abdulahi Hassan


    what extent do you agree with the above plan of management?I agree with other management but not the calcitriol to avoid further hyperparathyroidism.
    Discuss the potential role of dialysate calcium in patients with CKD-MBD
    it is recommended to use low dialysate calcium concentration between 1.25 and 1.50 mmol/L for better outcome .

  • Khaldon Rashed Ahmed Moqbil


    A- calcitriol should be stop to ⬇️phos b- use low ca 1.25 1.5 to avoid calcification

  • Rania Mahmoud


    C. To what extent do you agree with the above plan of management? I agree with cinacalcet but not with calcitriol to avoid worsening hyperphosphatemia
    D. Discuss the potential role of dialysate calcium in patients with CKD-MBD
    The guidelines recommended the use of dialysate calcium concentration between 1.25 and 1.50 mmol/L to maintain balance CKD-MBD. It is associated with better outcome in CKD-MBD .

  • Alaa Abdel Nasser


    I agree with cinacalcet but not with calcitriol and can use high dialysate calcium

    High dialysate calcium could be associated with risk of vascular calcification and a dynamic bone disease

  • Rabab Elrefaey


    You can now see the illustration of this part.

    C. To what extent do you agree with the above plan of management?

    KDIGO 2017 recommends that: In patients with CKD G5D requiring PTH-lowering therapy, calcimimetics, calcitriol, or vitamin D analogs, or a combination of calcimimetics with calcitriol or vitamin D analogs would be suggested (2B). Calcitriol should be avoided in this patient to avoid worsening hyperphosphatemia

    D. Discuss the potential role of dialysate calcium in patients with CKD-MBD.
    The KDIGO 2017 Clinical Practice Guidelines Update recommends using a dialysate calcium concentration between 1.25 and 1.50 mmol/L and it is associated with better outcome in CKD-MBD compared to higher dialysate calcium.

  • Abdulrahman Almutawakel


    PATIENT HAD SOME IMPROVEMENT IN PTH AND CALCIUM BUT HYPERPHOSPHATEMIA STILL THERE , SO MAY IT WILL BE BETTER TO STOP CALCITROL START NONCALCIUM BASED PHOSPHATE BINDER CONTINUE ON DIALYSIS WITH DIALYSTAE CALCIUM IN THE RANGE , AND FOLLOW UP , MAY CONSODERING ISOTOP SCAN FOR PARATHYROIED AND BONE BIOPSY IF POSSIBLE

  • Asmaa Salih KHUDHUR


    C. To what extent do you agree with the above plan of management?I’m not agree with this management plant as the use of calcitriol in the presence of hyperphosphatemia worsen the condition in edition to the use of low dialysate ca in the presence of low normal serum calcium.
    D. Discuss the potential role of dialysate calcium in patients with CKD-MBD.The guidelines recommended the use of dialysate ca in the range between 1.25-1.50 Mmol/ l to maintain balance CKD-MBD.

  • Israa Hammoodi


    C. The use of active form of vitamin D calcitriol causes increase in phosphorous and calcium so need to add paricalcitol with encourage phosphorous restrictions and increase dialysis adequacy
    D. Dialysate Ca increase in case of hypocalcimia and decrease when there hypercalcimia as calcium in Dialysate increase risk of a dynamic bone disease and vascular and cardiac calcification

  • Mahmoud Elsheikh


    To what extent do you agree with the above plan of management?j

    • Need to add a non-calcium phosphate binder. 
    • review the hidden P04 in the medication.

    Discuss the potential role of dialysate calcium in patients with CKD-MBD.

    • ERA-EDTA: customized dialysate calcium concentration. 
    • KDIGO 2009 :recommended a dialysate calcium concentration of 1.25 to 1.5 mmol/L, graded 2D. 
    • The KDIGO 2017 recommendations merely indicate that a neutral calcium balance requires 1.25 mmol/L calcium.
  • KAMAL ELGORASHI


    To what extent do you agree with the above plan of management?Add;

    • Add sevelamer.
    • Increase dialysate Ca to 1.5-2 mmol/l
    • Dietary restriction.
    • Optomise dialysis with Theranova filter
    • Patient bone profile phenotyping, BSAP, DXA scan, qCT Bone.
    • Paricalcitol injection.
    • 25 (OH) supplement.

    Dialysate calcium in CKD-MBD

    • Individualized dialysate calcium according to the patient’s metabolic bone profile, (one size fit all is not appropriate).
    • The use of dialysate calcium near to the physiological calcium levels, leas to improve bone prfile.
    • Modify calcium dialysate concentration according to the patient’s phenotype.
    • Consider the cardiovascular status and cardiovascular calcification and mortality risk.

    References

    • Bushinsky D.A.
    1. Contribution of intestine, bone, kidney, and dialysis to extracellular fluid calcium content.
    2. Clin J Am Soc Nephrol. 2010; 5: S12-S22
    • Johnson W.J.
    1. Optimum dialysate calcium concentration during maintenance hemodialysis.
    2. Nephron. 1976; 1: 241-258
    • National Kidney Foundation
    1. K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease.
    2. Am J Kidney Dis. 2003; 42: S1-S201
  • Nour Al Natout


    C. I won’t give the patient directly calcium mimetic. I will first try 25 OH vitamin D analogue, ERC or high selective vitamin D like paricalcitol due to low risk of further increasing phosphate level.
    and calcium containing phosphate binders. I can increase calcium in dialysate to 1.5 . If they fail i will use cinacalcet.

    D. High Dialysate Calcium can further suppress PTH . It is recommended to keep calcium in dialysate between 1.2-1.5 range to avoid extra osseous and cardiovascular calcification and low turnover bone disease.

  • Riaan Flooks


    C. To what extent do you agree with the above plan of management?

    • Discontinue Calcitriol use

    D. Discuss the potential role of dialysate calcium in patients with CKD-MBD.

    • KDIGO 2017 guidelines states that HIGHER Ca-dialysate, increases the risk of vascular and extravascular calcifications
  • MOHAMMED HAJI HASSAN


    C. To what extent do you agree with the above plan of management?
    stop calcitriol since it worsens the Hyperphosphatemia and increase dialysate calcium into 1.5mmol/L
    D. Discuss the potential role of dialysate calcium in patients with CKD-MBD
    KDIGO 2017 recommends using a dialysate calcium concentration between 1.25 and 1.50 mmol/L, higher dialysate calcium may aggravate the vascular or organ calcifications.

  • Rabab ALaa Eldin keshk Rabab


    C. To what extent do you agree with the above plan of management?
    Stop added of vit d because the continuation of rising po4 and use diyalisate with ca concentration 1.5
    D. Discuss the potential role of dialysate calcium in patients with CKD-MBD.
    Calcium dialysate level is better not to exceed 1.5 always low Ca dialysate preferable to be used in case of ABD or incase of severe vascular calcifications and avoid 1.7 to prevent metastatic calcification

  • HASSAN ALYAMMAHI


    C. To what extent do you agree with the above plan of management?
    The above plan kept Ca low by Cinacalcet and kept PO4 high by vitamin D.
    I would have added Ca based PO4 binder and increased dialysate Ca to 1.5

    D. Discuss the potential role of dialysate calcium in patients with CKD-MBD.
    Dialysate Ca of 1.25 can be used when there is hypercalcemia or ABD while dialysate Ca of 1.5 can be used in cases of symptomatic hypocalcemia or where it is though that asymptomatic hypocalcemia is driving SHPT

  • Emad mohamed mokbel Salem


    C. To what extent do you agree with the above plan of management?we should stop calcitriol because hyperphosphatemia
    use dialysate calcium 1.5 mmol/l to avoid hypocalcemia by cinacalcet

    D. Discuss the potential role of dialysate calcium in patients with CKD-MBD.KDIGO guideline advice for calcium dialysate to be 1.25–1.5 mmol/l
    avoid use of 1.7 mmol/l to avoid calcification
    and avoid 1 mmol/l to avoid hemodynaemic instability

  • Rihab Elidrisi


    To what extent do you agree with the above plan of management?The above plan leads to aggravating the phosphates level despite the fact that the PTH dropped to 700 under the action of calcitriol.

    Discuss the potential role of dialysate calcium in patients with CKD-MBD.Calcium dialysate level is better not to exceed 1.5
    always low Ca dialysate preferable to be used in case of ABD or incase of severe vascular calcifications .

  • Ahmed Altalawy


    C. To what extent do you agree with the above plan of management? Adding calcitriol causes more deterioration in P
    this plan missing use of P binders
    D. Discuss the potential role of dialysate calcium in patients with CKD-MBD. we can use different calcium dialysate concentrations to help more calcium control but better to avoid concentrations more than 1.5 to avoid aggravation of vascular calcifications .

  • Ahmed Wagih


    This plan effectively decreased reduced pth by almost 30% and improved calcium a little bit, but failed to correct hyperphosphatemia most likely due due to additon of calcitrol. i will DC calcitrol, add phosphate binder, combination from calcium based and non-calcium base phosphate binders. the role of low calcium dialysate is mainly in patients with adynamic bone disease and in patients with extensive cardiovascular calcification

  • Mahmud ISLAM


    I prefer low-dose cinacalcet (30 mg) and will change dialysate can be 1.5 mmol/L, but still, we have to control phosphorus to be able to control both hyperparathyroidisms and give both vitamin D analogues together with cinacalcet (can be each other day) to avoid hypocalcemia

    Will add on D. (later)

  • Weam El Nazer


    C. To what extent do you agree with the above plan of management?just needs to add a non-calcium phosphate binder. as the PO4 is the main stimulus of secondary hyperparathyroidism, and review the hidden P04 in the medication.

    Discuss the potential role of dialysate calcium in patients with CKD-MBD.
    International recommendations advise against a per-dialysis calcium load exceeding 1.5 mmol/L, which promotes vascular calcification. Calcium burden exacerbated this.

    ERA-EDTA standards propose a customized dialysate calcium concentration. Finally, the Kidney Disease Improving Global Outcomes (KDIGO) 2009 recommendations recommended a dialysate calcium concentration of 1.25 to 1.5 mmol/L, graded 2D. The KDIGO 2017 recommendations merely indicate that a neutral calcium balance requires 1.25 mmol/L calcium.

  • Elsayed Ghorab


    pt. still hyperphosphatemia
    why start cinacalcet now
    the plan neglect phosphorus binding agent

  • Ben Lomatayo


    C.To what extent do you agree with the above plan of management?

    • These management is generally not bad, it’s just requiring few touches e.g.,
    • Emphasize on the counselling and education as a continuous process.
    • Phosphates binders: Add combination of both calcium-based (calcium carbonate 1500 mg/day) plus non-calcium-based binders (sevelamer 800 mg t.d.s)
    • Aggressive dietary phosphate restriction
    • Change calcitriol to paricalcitol or calcifediol if available due its minimal effects on Ca & Pi
    • Aim for high dialysate Ca = 1.75 mmol/l
    • Frequent monitoring of Ca, Pi, & iPTH

    D. Discuss the potential role of dialysate calcium in patients with CKD-MBD.

    • Generally, dialysate Ca is in the range of 1.25 to 1.50 mmol/l. In CKD-MBD, it will depend on the patient profile:
    • High turnover bone disease: it may be preferable to aim for high unusual dialysate Ca content of 1.75 mmol/l. This may have suppressed effect on PTH at least in early phases of sHPT
    • Low turn over done disease: low dialysate Ca content is accepted as part of the management of cases of low bone turn over disease.
    • In all cases, the patient should be monitored closely to avoid the effect of either high or low dialysate Ca.
  • Ashraf Ahmed Mahmoud


    C. To what extent do you agree with the above plan of management?

    • I not agree with this plan.
    • correct low s.ca and high ph with use Calcium-based phosphate binder
    • Control of hyperphosphatemia should be done first before calcitriol and cinacalcet.
    • no need to use low calcium dialysate.

    D. Discuss the potential role of dialysate calcium in patients with CKD-MBD.

    • high dialysate calcium will cause hypercalcemia result in ABD.
    • low dialysate calcium results in SHPT.
    • Rabab Elrefaey


      The KDIGO 2017 Clinical Practice Guidelines Update recommends using a dialysate calcium concentration between 1.25 and 1.50 mmol/L and it is associated with better outcome in CKD-MBD compared to higher dialysate calcium

  • Hagar Ali


    A)I am disagree with this plane
    –treat hyperphosphatemia first with ca containing phosphate binder
    –use cinacalcet with cautious of hypocalcemia.
    –I will not use calcitriol with this high phosphate levels.
    –no role for low ca dialysate here.
    B)—Low ca dialysate can be used in cases of ADBD to stimulate PTH
    —high ca dialysate can be used in cases with low S.Ca to correct it and may affect PTH WE need to be cautious to avoid ADBD

    • Rabab Elrefaey


      The KDIGO 2017 Clinical Practice Guidelines Update recommends using a dialysate calcium concentration between 1.25 and 1.50 mmol/L and it is associated with better outcome in CKD-MBD compared to higher dialysate calcium

  • Ibrahim Omar


    C. To what extent do you agree with the above plan of management?

    • I do not agree with this plan.
    • Control of hyperphosphatemia should be done first before calcitriol and cinacalcet ttt
    • Calcium-based phosphate binders are indicated here to increase also serum calcium.
    • low calcium dialysate is also not indicated

    D. Discuss the potential role of dialysate calcium in patients with CKD-MBD.

    • high dialysate calcium will do +ve calcium balance and a possible a dynamic bone disease.
    • low dialysate calcium results in -ve calcium balance and 2ry hyperparathyroidism.
    • dialysate calcium should be optimized according to each patient.
    • Rabab Elrefaey


      The KDIGO 2017 Clinical Practice Guidelines Update recommends using a dialysate calcium concentration between 1.25 and 1.50 mmol/L and it is associated with better outcome in CKD-MBD compared to higher dialysate calcium

  • Mark Nagy Zaki Amin Mark


    C- I am against the use of calcitriol before control of po4 levels and dialysate calcium level should be more to supply calcium and to help to suppress PTH levels .
    D- dialysate calcium has an important role in CKD MBD patients either high turnover or low turnover cases
    In high turnover cases we should use the high dialysate calcium content to supply calcium and suppress PTH levels
    In low turnover cases we should use the least concentration to guard against hypercalcemia and adynamic bone disease.

    • Rabab Elrefaey


      The KDIGO 2017 Clinical Practice Guidelines Update recommends using a dialysate calcium concentration between 1.25 and 1.50 mmol/L and it is associated with better outcome in CKD-MBD compared to higher dialysate calcium

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