Desired PTH, phosphate & low or normal calcium
Patient Scenario: Desired PTH, phosphate & low or normal calcium
Assessing the Clinical and Laboratory Parameters
A patient who falls into this category has optimal management based on current knowledge. It is important to note that patients values tend to vary from month to month particularly with serum phosphate. Therefore, ongoing counseling is indicated.
Aproximately 6% of all patients are in this category.
Dialysis Prescription
Dialysis Prescription
No change is indicated in the dialysis prescription providing the patient meets criteria for adequacy of dialysis. A patient who is transferred to daily nocturnal hemodialysis will likely require adjustment in medication which may include addition of phosphate to the dialysate.
Phosphate and Calcium Management
Phosphate and Calcium Management
No change is indicated unless the patient is taking excessive amounts of elemental calcium (ie > 1.5 g/day) which will lead to a positive calcium balance and vascular soft tissue calcification. Vascular calcification may not be reversible. Introduction of a non-calcium binder (sevelamer/lanthanum) may be necessary if hyperphosphatemia occurs.
Vascular calcification may be assessed by conventional x-rays of the hands or pelvis and given a score of 0-4. A more sophisticated method involves electron-beam computed tomography (ECCT) or multislice (spiral) computed tomography (MSCT).
KDIGO 3.31 (August 2009)
In patients with CKD stages 3-5D, we suggest that a lateral abdominal radiograph can be used to detect the presence or absence of vascular calcification and an echocardiogram can be used to detect the presence of absence of vascular calcification, as reasonable alternatives to computed tomography base imaging (2C).
KDIGO 3.32 (August 2009)
We suggest that patients with CKD stages 3-5D with known vascular/valvular calcification be considered at highest cardiovascular risk (2A). It is reasonable to use this information to guide the management of CKD-MBD (not graded).
PTH Management
PTH Management
Vitamin D sterols/calcimimetics
No change in management is indicated. If in use, vitamin D sterols and calcimimetics should be continued.
Conventional vitamin D ie cholecalciferol (vitamin D3) or ergocalciferol (vitamin D2) may be added to the regime since there is accumulating evidence that extrarenal sites exist for conversion of vitamin D to an active form of vitamin D and this may be important in terms of immunity, development of cancer, autoimmune diseases, muscular strength, cardiovascular disease and cognitive function. D3 is more potent than vitamin D2 and patients should receive 800-1000 international units daily.
Other Options of Controversies in Management
Other Options of Controversies in Management
The presence or development of vascular calcification in dialysis carried increased morbidity and mortality and this group of patients requires intensive follow up.
References
References
1. Tokmak F et al. High-dose cholecalciferol to correct Vitamin D deficiency in hemodialysis patients: Nephrol Dial Transplant 2008;23:4016-4020.
Overview
Vitamin D deficiency is present in a majority of hemodialysis patients. Supplementation with cholecalciferol is safe, well tolerated and reasonable to replenish vitamin D stores in hemodialysis patients. However, only 57% of patients achieved recommended calcidiol levels (with 20,000 IU cholecalciferol/week) thus favouring additional dose-finding studies.
2. Disorders of Calcium Phosphorus and Magnesium Core Curriculum in Nephrology. Sharon Moe. Am J Kidney Dis 2005;45(1):213-218.Overview
A brief review of normal physiology, target organs and high or low concentrations of calcium, phosphorus and magnesium.
3. Agaston AS et al. Quantification of coronary artery calcium using ultrafast computed tomography. J Am Coll Cardiol 1990;15:827-832.Overview
Coronary artery calcification can be quantitated in renal failure patients and may correlate with morbidity and mortality.
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