Scenario 3 - Part 1:

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.
  • Asma Aljaberi


    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.

  • Hagar Ali


    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

  • Muhammad Soobadar


    would low PTH reduce risk of cardiovascular calcification?

  • Muhammad Soobadar


    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

  • Mohamed Abdulahi Hassan


    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)

  • Rasha Samir


    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.

  • Asmaa Salih KHUDHUR


    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

  • Nour Al Natout


    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.

  • Khaldon Rashed Ahmed Moqbil


    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.

  • Mahmoud Elsheikh


    A- Would you like to adjust/modify this treatment plan? and why?
    yes .

    • Stop calcium, one alfa
    • start phosphate binder. 

    B- What are other investigations needed for this patient?

    • lateral x ray of abdomen, BS.AL, DEXA scan .
    • echo .

    C- Can you comment on the increased risk of cardiovascular calcification in this patient.
    This patient is at increased risk of:

    • arterial media calcification
    • stiffening of his arteries
    • calcifications of his heart valve leaflets.
  • Riaan Flooks


    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
  • HASSAN ALYAMMAHI


    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.

  • Ahmed Wagih


    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

  • Mahmud ISLAM


    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.

  • Ashraf Ahmed Mahmoud


    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?

    • lateral x ray of abdomen .
    • BSALP
    • DEXA scan .
    • echo .

    C- Can you comment on the increased risk of cardiovascular calcification in this patient.
    High s.Ca
    high s,Pi
    High vit D

  • Israa Hammoodi


    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

    • Rasha Samir


      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.

  • Rabab ALaa Eldin keshk Rabab


    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

  • Abdulrahman Almutawakel


    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

  • Rihab Elidrisi


    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% .

  • Ahmed Altalawy


    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 .

  • Rania Mahmoud


    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
    

  • Ben Lomatayo


    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?

    1. ALP
    2. Vitamin D levels
    3. Lateral abdominal X ray for vascular calcification
    4. Echo/ CXR for valvular calcification
    5. CAC score
    6. 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.
  • Alaa Abdel Nasser


    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

  • KAMAL ELGORASHI


    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;

    • Longterm HD.
    • Hyperphosphatemia.
    • Hypercalcemia with Ca supplement.
  • Elsayed Ghorab


    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

  • MOHAMMED HAJI HASSAN


    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

  • Mark Nagy Zaki Amin Mark


    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

  • Weam El Nazer


    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 

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