Therapeutic Options:
Dialysis Prescription
Depending on the phosphrous level, additional PO4 may need to be added to the dialysate. Dialysate calcium bath should be individualized to correct serum calcium into the normal range. Increasing calcium bath may further suppress the PTH level.
Phosphate and Calcium Management
Liberalization of the diet may help raise the phosphate level. If there is significant cachexia, intradialytic TPN may be considered after modification of the diet and supplements. The dose of calcium containing phosphate binder in this patient needs to be reassessed given the presence of both normal or low calcium and hypophosphatemia. A decrease in calcium dose given with meals, and a switch to calcium supplementation away from times of food ingestion may improve both parameters. If the calcium is normal, a simple reduction in binder dose may be all that is required. If the patient is being managed primarily with non-calcium containing binders, the dose should be reduced. Aluminum containing binders should be discontinued.
A Vitamin D sterol will increase both calcium and phosphate absorption and may return both these parameters to normal, but may further suppress the PTH level.
PTH Management
Although the use of vitamin D seems unlikely given that both the calcium and the phosphate are low, it should be discontinued while liberating the dietary phosphate and providing calcium supplementation.
If a Calcimimetic is being used it should be discontinued until the PTH starts to exceed the target range.
Other Options of Controversies in Management
Although therapeutic use of teriparatide is being considered for patients who fall into this group, such an approach is currently experimental.
1. Puig-Domingo M, D?´az G, Nicolau J, Ferna´ndez C, Rueda S, Halperin I. Successful treatment of vitamin D unresponsive hypoparathyroidism with multi pulse subcutaneous infusion of teriparatide. Eur J Endocrinol. 2008; 159:653–657.
2. Mahajan A, Narayanan M, Jaffers G, Concepcion L. Hypoparathyroidism associated with severe mineral bone disease postrenal transplantation, treated successfully with recombinant PTH Hemodial Int. 2009 Oct;13(4):547-50. Epub 2009 May 28
3. A Clinical Trial “The Effects of Ibandronate or Teriparatide Therapy on Bone Histology and Biochemical Indices in Patients on Hemodialysis With Low Bone Mineral Density” at Clinical Trials.Gov http://www.clinicaltrials.gov/ct2/show/NCT00446589?term=Teriparatide&cond=hemodialysis&rank=1
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