Desired PTH, Phosphate and Hypercalcemia

Dialysis Prescription

A decrease in dialysate calcium by 0.25-0.5 mmol/L (0.5-1.0 mEq/L) may alleviate hypercalcemia and allow a modest rise in the serum phosphate.

Phosphate and Calcium Management

Phosphate and Calcium Management

The use and quantity of calcium binders needs to be reduced to provide normocalcemia and a normal phosphate.  An additional source of calcium may be calcium-containing antiacids which the patient obtains without a prescription or the knowledge of his medical team.  Excess calcium containing nutrients may be a contributing factor.

KDIGO Recommendation 4.1.5

In patients with CKD stages 3-5D and hyperphosphatemia, we recommend restricting the dose of calcium-based phosphate binders and/or the dose of calcitriol or vitamin D analogue in the presence of persistent or recurrent hypercalcemia (IB).

PTH Management

Vitamin D sterols

PTH may rise when correcting hypercalcemia and hypophosphatemia.  Active Vitamin D sterols would likely contribute to further hypercalcemia would not be an attractive option at present.

Calcimimetics

Calcimimetics would lower the PTH and phosphate and perhaps normalize the serum calcium, but is not an attractive option.

Other options of Controversies in Management

This combination ie. desired PTH, low or normal phosphate and normal or high calcium may occur with more intensive dialysis such as short daily hemodialysis or daily nocturnal hemodialysis.  Addition of phosphate to the dialysate with lowering of the dialysate calcium may correct the abnormalities.