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
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.
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.
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 .
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 .
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.
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
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.
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
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.
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.
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
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
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
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 .
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 .
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
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)
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.
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.
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
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
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
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
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.
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
I don’t agree with some points
according to KDIGO guidelines dialysate calcium between 1.25-1.5 mmol/l
C. To what extent do you agree with the above plan of management?
Agre,e except for calcitriol
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.
C calcitriol can make phosphate worse thererfore avoid
D kdigo recommend calcium dialysate 1.25-1.50 mmol/l
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.
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 .
A- calcitriol should be stop to ⬇️phos b- use low ca 1.25 1.5 to avoid calcification
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 .
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
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.
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
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.
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
To what extent do you agree with the above plan of management?j
Discuss the potential role of dialysate calcium in patients with CKD-MBD.
To what extent do you agree with the above plan of management?Add;
Dialysate calcium in CKD-MBD
References
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.
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.
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.
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
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
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
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 .
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 .
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
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)
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.
pt. still hyperphosphatemia
why start cinacalcet now
the plan neglect phosphorus binding agent
Why you did not agree, dr Elsayed with adding cinacalcet to control hyperparathyroidism?
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.
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.
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
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
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
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.
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
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.
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