A 40-years-old male, ESKD for10 years ago. H/O of low trauma fracture of Lt forearm and Lt hip. The patient was maintained on oral alfacalcidol 1 mcg per day and oral calcium gluconate 1000 mg per day.
The following laboratory investigations revealed:
Test
Value
S. Creatinine
5 mg/dL
S. corrected Calcium
10.2 mg/dL
S. Phosphorus
8.2 mg/dL
iPTH
250 pg/mL
A- Would you like to adjust/modify this treatment plan? and why?
B- What are other investigations needed for this patient?
C- Can you comment on the increased risk of cardiovascular calcification in this patient.
46 Comments
Amna Kununa
A- Would you like to adjust/modify this treatment plan? and why?
stopped Calcium supplement- mild hyperCa (positive Ca load)
decreased alfacalcidol: increase intestinal absorption of Ca and Pi
for hyperPi in addition to decreased alfacalcidol
Dietitian review review dialysis adequacy add non-calcium base phosphate binder like Sevelamer
B- What are other investigations needed for this patient?
Mg
Vit D
BSAP
DXA
C- Can you comment on the increased risk of cardiovascular calcification in this patient.
vascular calcification (medial calcification) initiated by hyperphosphatemia, hypercalcemia, and, possibly, high PTH as well as oxidative stress.
Hyperphosphatemia increases activity of the sodium-dependent phosphate cotransporters, promoting phosphate uptake by vascular smooth muscle cells and upregulating genes associated with matrix mineralization.
Hypercalcemia and hyperphosphatemia both increase the release of vascular smooth muscle cell-derived matrix vesicles, resulting in the deposition of hydroxyapatite.
A- Would you like to adjust/modify this treatment plan? and why?
Patient has hyperphosphatemia with mild hypercalcemia. Alfacalcidol is VDR analoge which would increase Ca and phosphate absorption. We need to decrease alfacalcidol dose to 0.5 mcg PO OD, stop calcium gluconate and start sevelamer.
B- What are other investigations needed for this patient?
Bone profile
Vitamin D
DXA scan
C- Can you comment on the increased risk of cardiovascular calcification in this patient?
Patient with ESRD has increased risk of calcification due to hyperphosphatemia and tertiary hyperparathyroidism leading to high calcium level.
Meds like calcium carb or calcium-containing phosphate binders can also induce hypercalcemia and, in the long term, can increase the risk for vascular calcification.
A:stop ca gluconate and use sevelamer as a phosphate binder
use cinacalcet and stop one alpha
to avoid CV calcification
B:ALP,DEXA scan
C:hyperphosphatemia plus using ca binder and one alpha will increase CV calcification
A- stop calcium binders and change to sevalamer
B check vitamin D level
C hyperphosphataemia and also calcium binders would increase risk of cardiovascular calcification
A-Would you like to adjust/modify this treatment plan? and why?
yes, stop alfacalcidol and calcium. because of hyperphosphatemia and hypercalcemia sevelamer B-What are other investigations needed for this patient?vitamin D , alkaline phosphate
DEXA scan C- Can you comment on the increased risk of cardiovascular calcification in this patient. is the cadiovascular calcifications. (arterial and valvular)
Would you like to adjust/modify this treatment plan? and why?
The patient should stop alfacalcidol and calcium supplementation because of hypercalcemia and hyperphosphatemia. Non calcium containing phosphate binders like sevelamer is of value with no risk of hypercalcemia.
B. What are other investigations needed for this patient?
25 (OH) vitamin D and bone specific alkaline phosphatase should be assessed.
DEXA scan is helpful in determining bone mineral density in CKD patients.
C. Can you comment on the increased risk of cardiovascular calcification in this patient.
Hyperphosphatemia is found to be strongly linked with vascular calcification via promoting calcification of VSMCs. Moreover, calcium based phosphate binders and high doses of active vitamin D together with long dialysis vintage carry higher risk of cardiovascular calcifications.
Would you like to adjust/modify this treatment plan? and why?
stop alfacalcidol and calcium
start sevelamer
B- What are other investigations needed for this patient?
BSAP
DEXA
Abdominal X R lateral view Can you comment on the increased risk of cardiovascular calcification in this patient.
arterial media calcification
arterial stiffness
valvular calcification
A. Stop calcium and vitamin D due to increased risk of hypercalcemia and low turnover bone disease. Start sevelamer
B. Dexa, bone specific AP, xray abdomen lateral, echocardiography.
Prolonged use of calcium , positive calcium balance, hyperphosphatemia are all risk of increased vascular calcification.
A- Would you like to adjust/modify this treatment plan? and why?
I would discontinue the Calcium-containing Phosphate Binder, and change onto Sevelamer – since the prolonged use of Calcium-containing phosphate binders which causes the hypercalcemia and hyperphosphatemia would cause cardiovascular disease
B- What are other investigations needed for this patient?
25(OH)D
BSAP
DEXA scan
Possibly a bone biopsy
C- Can you comment on the increased risk of cardiovascular calcification in this patient.
The prolonged dialysis history and the Calcium-containing phosphate binders, accelerates the cardiovascular risk
A- Would you like to adjust/modify this treatment plan? and why? Patient may not need all the VitD and Ca he’s taking, the fact he had fracture means he may have ABD, and could be depositing his Ca in his soft tissues
B- What are other investigations needed for this patient? bALP, vitamin D level, DEXA, may need bone biopsy as it is difficult with the current investigation to decide what bone disease he has.
C- Can you comment on the increased risk of cardiovascular calcification in this patient. This patient is at increased risk of arterial media calcification and stiffening of his arteries in addition of calcifications of his heart valve leaflets.
Actually, Calcium based phosphate binders and high doses of active vitamin D together with long dialysis vintage carry higher risk of cardiovascular calcifications
A- Would you like to adjust/modify this treatment plan? and why?the patient has hyperphosphatemia, serum calcium in upper limit and intact PTH within desired range.
i modify this plan to manage phosphorus and calcium more adequetly, i will stop calcium gluconate, add sevelmar and decrease alfacalcidol
in these patients there is diminished buffering capacity of the bone, so calcium and phosphorus willbe deposited in the blood vessels
What are other investigations needed for this patient? alkaline phosphatase level: to decide turn over status
dexa scan:- to detect osteoporosis or osteopenia
Can you comment on the increased risk of cardiovascular calcification in this patient.
cardiovascular disease is the most common cause of mortality in CKD patients,our patient has multiple risk factors for vascular calcification, including:
postive calcium balance
hyperphosphatemia
oral calcium base phosphate binders
long dialysis duration
For this patient, I will concentrate on phosphorus lowering (medical treatment and diet). Stooping alfacalcidol is needed because of hyperphosphatemia and hypercalcemia, and PTH is within target.
After stopping alfacalcidol and control of phosphorus, we need to evaluate the bone quality, DEXA scan may help us, but if available also, we can perform a bone biopsy.
This patient have high risk of calcification because of high phosphorous and calcium load.
Thanks! Calcium based phosphate binders and high doses of active vitamin D together with long dialysis vintage represent the main risk factors for cardiovascular calcifications
A- Would you like to adjust/modify this treatment plan? and why?
Stop calcium and one alfa due to high calcium, phosphorous that might lead to cardio-vascular calcification and mortality
B- What are other investigations needed for this patient?
Vitamin D level, Bsap, echo, lateral x ray of abdomen
C- Can you comment on the increased risk of cardiovascular calcification in this patient
The increased level of calcium and phosphorus causing cardio-vascular calcification and mortality
High doses of Vit D and calcium containing phosphate binders contribute to the risk of cardiovascular calcification. long dialysis vintage additionally carries higher risk of cardiovascular calcifications.
A- Would you like to adjust/modify this treatment plan? and why?
We should stop ca and Alphacalcidol supplement because po4 high increase risk of cardiovascular calcification
B- What are other investigations needed for this patient?
Vit d level, Echo,
Xary I. Abdomen to see aorta
C- Can you comment on the increased risk of cardiovascular calcification in this patient.
Yes these patient high risk for cardiovascular calcification dueto hypercalcimia and hyperphosphatemia and long standing ckd and intake of vit d
A- Would you like to adjust/modify this treatment plan? and why?Yes , i will stop calcium and alfacalcidol b/o hypercalcemia and hyperphosphatemia .
What are other investigations needed for this patient? I will do full lab tests , also i will request Echocardiography , xray to look for vascular calcification.
Can you comment on the increased risk of cardiovascular calcification in this patient. Patient has high risk for vascular calcification b/o ckd+ calcium ,alfacalcidol and high pth
Would you like to adjust/modify this treatment plan? And why?i will stop alfacalcidol and CA supplements as this patient has hypercalcemia and hyperphosphatemia.
His PTH is towards the low level, but we need to have a look at the trends of PTH to decide regarding PTH .
What are other investigations needed for this patient?
we need to check for BSALPand check Mg and PTH
will need to do EXA scan and x ray
will need to do echo and plain abdominal x ray looking for calcifications
Can you comment on the increased risk of cardiovasculaTHis patient have been on dialysis for the last 10 years adding to the fact that he has hypercalcemia and hyperphophatemia which will increase his vascular calcifications .
A we all know that the risk of vascular calcification on patient on long term dialysis may exceed 80% .
A- Would you like to adjust/modify this treatment plan? and why? Hold calcium and alfacalcidol , start non calcium containing P binder
B- What are other investigations needed for this patient? KT/V , ECHO , LAT Abominal X ray C- Can you comment on the increased risk of cardiovascular calcification in this patient. Long history of CKD with high P and continued oral calcium intake increases risk of vascular calcification .
A- Would you like to adjust/modify this treatment plan? and why?
· Stop alfacalcidol , calcium gluconate to reduce hyperphosphatemia and hypercalcemia
· Add Sevalamer for hyperphosphatemia initially with1600 mg.with meals TID
· Advice the patient with a low phosphate diet. B- What are other investigations needed for this patient?
· Alkaline phosphatase and bone specific alkaline phosphatase
· 25-hydroxy Vit-D
· Serum mg
· Ecchocardiogram
· DEXA scan
· Bone biopsy : gold standard C- Can you comment on the increased risk of cardiovascular calcification in this patient.
· ESRD with Longterm hemodialysis (10 years ago)
· Hypercalcemia and hyperphosphatemia
. Vascular calcifications is common in HD patient
A- Would you like to adjust/modify this treatment plan? and why?
Yes, he developed side effect of vitamin D and calcium supplementation in the form of hypercalcemia, hyperphosphatemia and PTH probably coming to the lower values though we don’t know his baseline.
B- What are other investigations needed for this patient?
ALP
Vitamin D levels
Lateral abdominal X ray for vascular calcification
Echo/ CXR for valvular calcification
CAC score
DEXA scan to evaluate for osteoporosis.
C- Can you comment on the increased risk of cardiovascular calcification in this patient.
The risk of vascular calcification may exceed 80% in hemodialysis patients. This is made worse by unwise use of calcium and vitamin D supplementation. Vascular calcification is linked to high-risk cardiovascular morbidity and mortality.
Would you like to adjust/modify this treatment plan? and why?
Stop alfacalcidol.
Stop Calcium carbonate.
Add sevelamer.
Add Alendronate.
What are other investigations needed for this patient?
BSALP.
Mg
DXA and qCT bone scan.
Sclerostin level
bone biomarkers
+/- bone biopsy
Can you comment on the increased risk of cardiovascular calcification in this patient.In this patient according to the above data, the CV calcification risk is attributed to;
the investigation revealed
upper level calcium
hyperphosphatemia
PTH Can accept in esrd pt.
pt. undergoes of over dose of treatment
so plan stop alfacalcidol and calcium gluconate
start medication :-
non-calcium phosphorus binding for hyperphosphatemia
can added analogue selective vit. d paricalcitol many factors increased risk of cardiovascular calcification in this patient.hyprerphosphatemia
pth
hyper calcemia
fgf23
A- Would you like to adjust/modify this treatment plan? and why?
Stop Alfacalcidol and calcium gluconate since phosphate and iPTH levels are high. I will modify it by adding sevelamer and advice the patient should eat a low phosphate diet.
B- What are other investigations needed for this patient?
vitamin D level, PTH, ALP,kt/v, and Dexa scan
C- Can you comment on the increased risk of cardiovascular calcification in this patient
The risk of vascular calcification of this patient is due to high phosphate, PTH leading to hypercalcemia which will then deposit on the vascular and cardiac valves
A- calcium dose should be reduced and alphacalcidol should be withheld temporarily until po4 levels are controlled with non calcium containing po4 binders as sevelamer together with diet control and extended nocturnal dialysis if needed
B- KT/V to assess efficiency of HD sessions , 25(OH) vit D assay , alkaline phosphatase
C- high normal calcium and increased po4 levels increase cardiovascular morbidity and mortality in this patient
A- Would you like to adjust/modify this treatment plan? and why?
Yes, I will DC the calcium and alfa-calcidiol due to the high serum Ca and PO4. I will recommend adding a non-calcium PO4 binder.
B- What are other investigations needed for this patient?
KT/V, Bone specific Alkaline phosphatase, 25-hydroxy Vit-D, Echo, and lateral Abdomen X-ray.
C- Can you comment on the increased risk of cardiovascular calcification in this patient?Even in early CKD, vascular calcification causes cardiovascular disease, a lower life expectancy, and increased death. Cardiac valve calcification increases the risk of cardiovascular dysfunction.
Vascular and valvular calcification involves various systems. Besides calcium and phosphate precipitation. High serum phosphate is the most significant non-traditional risk factor for vascular calcification in CKD patients.
FGF23 and its co-receptor Klotho have also been related to vascular calcification
A- Would you like to adjust/modify this treatment plan? and why?
Dietitian review
review dialysis adequacy
add non-calcium base phosphate binder like Sevelamer
B- What are other investigations needed for this patient?
C- Can you comment on the increased risk of cardiovascular calcification in this patient.
A- Would you like to adjust/modify this treatment plan? and why?
Patient has hyperphosphatemia with mild hypercalcemia. Alfacalcidol is VDR analoge which would increase Ca and phosphate absorption. We need to decrease alfacalcidol dose to 0.5 mcg PO OD, stop calcium gluconate and start sevelamer.
B- What are other investigations needed for this patient?
Bone profile
Vitamin D
DXA scan
C- Can you comment on the increased risk of cardiovascular calcification in this patient?
Patient with ESRD has increased risk of calcification due to hyperphosphatemia and tertiary hyperparathyroidism leading to high calcium level.
Meds like calcium carb or calcium-containing phosphate binders can also induce hypercalcemia and, in the long term, can increase the risk for vascular calcification.
A:stop ca gluconate and use sevelamer as a phosphate binder
use cinacalcet and stop one alpha
to avoid CV calcification
B:ALP,DEXA scan
C:hyperphosphatemia plus using ca binder and one alpha will increase CV calcification
would low PTH reduce risk of cardiovascular calcification?
A- stop calcium binders and change to sevalamer
B check vitamin D level
C hyperphosphataemia and also calcium binders would increase risk of cardiovascular calcification
A-Would you like to adjust/modify this treatment plan? and why?
yes, stop alfacalcidol and calcium. because of hyperphosphatemia and hypercalcemia
sevelamer
B-What are other investigations needed for this patient?vitamin D , alkaline phosphate
DEXA scan
C- Can you comment on the increased risk of cardiovascular calcification in this patient.
is the cadiovascular calcifications. (arterial and valvular)
Would you like to adjust/modify this treatment plan? and why?
The patient should stop alfacalcidol and calcium supplementation because of hypercalcemia and hyperphosphatemia. Non calcium containing phosphate binders like sevelamer is of value with no risk of hypercalcemia.
B. What are other investigations needed for this patient?
25 (OH) vitamin D and bone specific alkaline phosphatase should be assessed.
DEXA scan is helpful in determining bone mineral density in CKD patients.
C. Can you comment on the increased risk of cardiovascular calcification in this patient.
Hyperphosphatemia is found to be strongly linked with vascular calcification via promoting calcification of VSMCs. Moreover, calcium based phosphate binders and high doses of active vitamin D together with long dialysis vintage carry higher risk of cardiovascular calcifications.
Would you like to adjust/modify this treatment plan? and why?
stop alfacalcidol and calcium
start sevelamer
B- What are other investigations needed for this patient?
BSAP
DEXA
Abdominal X R lateral view
Can you comment on the increased risk of cardiovascular calcification in this patient.
arterial media calcification
arterial stiffness
valvular calcification
A. Stop calcium and vitamin D due to increased risk of hypercalcemia and low turnover bone disease. Start sevelamer
B. Dexa, bone specific AP, xray abdomen lateral, echocardiography.
Prolonged use of calcium , positive calcium balance, hyperphosphatemia are all risk of increased vascular calcification.
A- stop ca and vit d analogous
b- dexa scan and bone biopsy and x-ray abdomin
c-high risk for calcification valve and art.
A- Would you like to adjust/modify this treatment plan? and why?
yes .
B- What are other investigations needed for this patient?
C- Can you comment on the increased risk of cardiovascular calcification in this patient.
This patient is at increased risk of:
A- Would you like to adjust/modify this treatment plan? and why?
B- What are other investigations needed for this patient?
C- Can you comment on the increased risk of cardiovascular calcification in this patient.
A- Would you like to adjust/modify this treatment plan? and why?
Patient may not need all the VitD and Ca he’s taking, the fact he had fracture means he may have ABD, and could be depositing his Ca in his soft tissues
B- What are other investigations needed for this patient?
bALP, vitamin D level, DEXA, may need bone biopsy as it is difficult with the current investigation to decide what bone disease he has.
C- Can you comment on the increased risk of cardiovascular calcification in this patient.
This patient is at increased risk of arterial media calcification and stiffening of his arteries in addition of calcifications of his heart valve leaflets.
Actually, Calcium based phosphate binders and high doses of active vitamin D together with long dialysis vintage carry higher risk of cardiovascular calcifications
A- Would you like to adjust/modify this treatment plan? and why?the patient has hyperphosphatemia, serum calcium in upper limit and intact PTH within desired range.
i modify this plan to manage phosphorus and calcium more adequetly, i will stop calcium gluconate, add sevelmar and decrease alfacalcidol
in these patients there is diminished buffering capacity of the bone, so calcium and phosphorus willbe deposited in the blood vessels
What are other investigations needed for this patient? alkaline phosphatase level: to decide turn over status
dexa scan:- to detect osteoporosis or osteopenia
Can you comment on the increased risk of cardiovascular calcification in this patient.
cardiovascular disease is the most common cause of mortality in CKD patients,our patient has multiple risk factors for vascular calcification, including:
postive calcium balance
hyperphosphatemia
oral calcium base phosphate binders
long dialysis duration
Great! Thanks!
For this patient, I will concentrate on phosphorus lowering (medical treatment and diet). Stooping alfacalcidol is needed because of hyperphosphatemia and hypercalcemia, and PTH is within target.
After stopping alfacalcidol and control of phosphorus, we need to evaluate the bone quality, DEXA scan may help us, but if available also, we can perform a bone biopsy.
This patient have high risk of calcification because of high phosphorous and calcium load.
Calcium containing phosphate binders would be better replaced by non-calcium containing phosphate binders.
A- Would you like to adjust/modify this treatment plan? and why?yes .
Stop calcium and one alfa and start phosphate binder.
B- What are other investigations needed for this patient?
C- Can you comment on the increased risk of cardiovascular calcification in this patient.
High s.Ca
high s,Pi
High vit D
Thanks! Calcium based phosphate binders and high doses of active vitamin D together with long dialysis vintage represent the main risk factors for cardiovascular calcifications
A- Would you like to adjust/modify this treatment plan? and why?
Stop calcium and one alfa due to high calcium, phosphorous that might lead to cardio-vascular calcification and mortality
B- What are other investigations needed for this patient?
Vitamin D level, Bsap, echo, lateral x ray of abdomen
C- Can you comment on the increased risk of cardiovascular calcification in this patient
The increased level of calcium and phosphorus causing cardio-vascular calcification and mortality
High doses of Vit D and calcium containing phosphate binders contribute to the risk of cardiovascular calcification. long dialysis vintage additionally carries higher risk of cardiovascular calcifications.
A- Would you like to adjust/modify this treatment plan? and why?
We should stop ca and Alphacalcidol supplement because po4 high increase risk of cardiovascular calcification
B- What are other investigations needed for this patient?
Vit d level, Echo,
Xary I. Abdomen to see aorta
C- Can you comment on the increased risk of cardiovascular calcification in this patient.
Yes these patient high risk for cardiovascular calcification dueto hypercalcimia and hyperphosphatemia and long standing ckd and intake of vit d
DEXA scan would be helpful in determining bone mineral density in CKD patients
A- Would you like to adjust/modify this treatment plan? and why?Yes , i will stop calcium and alfacalcidol b/o hypercalcemia and hyperphosphatemia .
What are other investigations needed for this patient?
I will do full lab tests , also i will request Echocardiography , xray to look for vascular calcification.
Can you comment on the increased risk of cardiovascular calcification in this patient.
Patient has high risk for vascular calcification b/o ckd+ calcium ,alfacalcidol and high pth
Furthermore, DEXA scan would be helpful in determining bone mineral density.
Would you like to adjust/modify this treatment plan? And why?i will stop alfacalcidol and CA supplements as this patient has hypercalcemia and hyperphosphatemia.
His PTH is towards the low level, but we need to have a look at the trends of PTH to decide regarding PTH .
What are other investigations needed for this patient?
we need to check for BSALPand check Mg and PTH
will need to do EXA scan and x ray
will need to do echo and plain abdominal x ray looking for calcifications
Can you comment on the increased risk of cardiovasculaTHis patient have been on dialysis for the last 10 years adding to the fact that he has hypercalcemia and hyperphophatemia which will increase his vascular calcifications .
A we all know that the risk of vascular calcification on patient on long term dialysis may exceed 80% .
Great, Thank you!
A- Would you like to adjust/modify this treatment plan? and why? Hold calcium and alfacalcidol , start non calcium containing P binder
B- What are other investigations needed for this patient? KT/V , ECHO , LAT Abominal X ray
C- Can you comment on the increased risk of cardiovascular calcification in this patient. Long history of CKD with high P and continued oral calcium intake increases risk of vascular calcification .
Additionally, DEXA scan would be helpful in determining bone mineral density in CKD patient
A- Would you like to adjust/modify this treatment plan? and why?
· Stop alfacalcidol , calcium gluconate to reduce hyperphosphatemia and hypercalcemia
· Add Sevalamer for hyperphosphatemia initially with1600 mg.with meals TID
· Advice the patient with a low phosphate diet.
B- What are other investigations needed for this patient?
· Alkaline phosphatase and bone specific alkaline phosphatase
· 25-hydroxy Vit-D
· Serum mg
· Ecchocardiogram
· DEXA scan
· Bone biopsy : gold standard
C- Can you comment on the increased risk of cardiovascular calcification in this patient.
· ESRD with Longterm hemodialysis (10 years ago)
· Hypercalcemia and hyperphosphatemia
. Vascular calcifications is common in HD patient
Great job!
A- Would you like to adjust/modify this treatment plan? and why?
B- What are other investigations needed for this patient?
C- Can you comment on the increased risk of cardiovascular calcification in this patient.
Great! So we should stop alfacalcidol and calcium supplementation.
stop alfacalcidol to reduce hyperphosphatemia and calcium gluconate
start sevelamer
diet control (low phosphate )
ensure dialysis adequacy
alkaline phosphatase and bone specific alkaline phosphatase
serum mg
DEXA scan
bone biopsy : gold standard
hyperphosphatemia and hypercalcemia
being ESKD
all increase risk of cardiovascular calcification
The long dialysis vintage is another important risk factor
Would you like to adjust/modify this treatment plan? and why?
What are other investigations needed for this patient?
Can you comment on the increased risk of cardiovascular calcification in this patient.In this patient according to the above data, the CV calcification risk is attributed to;
Excellent job!
the investigation revealed
upper level calcium
hyperphosphatemia
PTH Can accept in esrd pt.
pt. undergoes of over dose of treatment
so plan stop alfacalcidol and calcium gluconate
start medication :-
non-calcium phosphorus binding for hyperphosphatemia
can added analogue selective vit. d paricalcitol
many factors increased risk of cardiovascular calcification in this patient.hyprerphosphatemia
pth
hyper calcemia
fgf23
25 (OH) vitamin D and bone specific alkaline phosphatase should be assessed.
A- Would you like to adjust/modify this treatment plan? and why?
Stop Alfacalcidol and calcium gluconate since phosphate and iPTH levels are high. I will modify it by adding sevelamer and advice the patient should eat a low phosphate diet.
B- What are other investigations needed for this patient?
vitamin D level, PTH, ALP,kt/v, and Dexa scan
C- Can you comment on the increased risk of cardiovascular calcification in this patient
The risk of vascular calcification of this patient is due to high phosphate, PTH leading to hypercalcemia which will then deposit on the vascular and cardiac valves
The long dialysis vintage is an additional risk factor
A- calcium dose should be reduced and alphacalcidol should be withheld temporarily until po4 levels are controlled with non calcium containing po4 binders as sevelamer together with diet control and extended nocturnal dialysis if needed
B- KT/V to assess efficiency of HD sessions , 25(OH) vit D assay , alkaline phosphatase
C- high normal calcium and increased po4 levels increase cardiovascular morbidity and mortality in this patient
DEXA scan would be helpful in determining bone mineral density.
A- Would you like to adjust/modify this treatment plan? and why?
Yes, I will DC the calcium and alfa-calcidiol due to the high serum Ca and PO4. I will recommend adding a non-calcium PO4 binder.
B- What are other investigations needed for this patient?
KT/V, Bone specific Alkaline phosphatase, 25-hydroxy Vit-D, Echo, and lateral Abdomen X-ray.
C- Can you comment on the increased risk of cardiovascular calcification in this patient?Even in early CKD, vascular calcification causes cardiovascular disease, a lower life expectancy, and increased death. Cardiac valve calcification increases the risk of cardiovascular dysfunction.
Vascular and valvular calcification involves various systems. Besides calcium and phosphate precipitation. High serum phosphate is the most significant non-traditional risk factor for vascular calcification in CKD patients.
FGF23 and its co-receptor Klotho have also been related to vascular calcification
Dexa scan may be also needed.