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![Case 2
• Ms L S is a 29-year-old woman with recently diagnosed lupus
nephritis.
• She is referred to you for management of her stage 3 CKD
(estimated glomerular filtration rate [eGFR]= 35 mL/min).
• She is asymptomatic with regard to her lupus.
• She does not smoke and attends excercise twice each week.
• She is married with a 7-year-old child.](https://image.slidesharecdn.com/ckdmbdmih-160203070216/75/Ckd-mbd-mih-23-2048.jpg)
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Ckd mbd mih
This document discusses chronic kidney disease-mineral and bone disorder (CKD-MBD). It defines CKD-MBD and renal osteodystrophy. It notes that CKD-MBD is characterized by abnormalities in calcium, phosphorus, PTH, or vitamin D metabolism. It also discusses secondary hyperparathyroidism in CKD and characteristics of major CKD-related bone diseases. The document then presents two patient case studies and questions related to interpreting lab results and determining appropriate treatment steps for managing mineral and bone disorders in the patients.
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Ckd mbd mih
- 1. Chronic Kidney Disease- MineralBone Disorders Kamal Mohamed Okasha MD. Prof of Nephrology, Tanta Uinversity ISN Sistership Renal Program with Sheffield instite.
- 5. Definition of CKD-Mineraland Bone Disorder A systemic disorder of mineral and bone metabolism due to CKD manifested by either one or a combination of the following: Abnormalities of calcium, phosphorus, PTH, or vitamin D metabolism Abnormalities in bone turnover, mineralization, volume, linear growth, or strength Vascular or other soft tissue calcification Moe S, et al. Kidney Int 69: 1945, 2006
- 6. Definition of RenalOsteodystrophy Renal osteodystrophy is an alteration of bone morphology in patients with CKD. It is one measure of the skeletal component of the systemic disorder of CKD-MBD that is quantifiable by histomorphometry of bone biopsy. Moe S, et al. Kidney Int 69: 1945, 2006
- 7. Chronic Kidney Disease-RelatedMineral and Bone Disorder: Public Health Problem. Kerry Willis PhD National Kidney Foundation
- 8. Secondary hyperparathyroidism encompassesmost of the biochemical abnormalities that characterize CKD-MBD. Causes of secondary hyperparathyroidism: Phosphate retention. Decreased free calcium concentration. Decreased 1,25-dihydroxyvitamin D (calcitriol) concentration. Reduced expression of vitamin D receptors (VDRs). Calcium-sensing receptors (CaSR). Fibroblast growth factor receptors (FGFRs), and klotho in the parathyroid glands.
- 10. Characteristics of themajor CKD-related bone diseases: Osteitis fibrosa cystica Adynamic bone disease Osteomalacia Mixed uremic osteodystrophy
- 11. Case 1 • MrSM is a 53-year-old man with end-stage renal disease (ESRD) secondary to type 2 diabetes. • He also has hypertension and hypercholesterolemia. His medications include insulin, an antihypertensive, and a cholesterol-lowering agent. • He has recently begun hemodialysis. He quit smoking cigarettes 1 year ago; he had a 30-year pack/day history. • He is a retired high school teacher. • His physical activity is limited to indoor.
- 12. • Which ofthe following is most likely to be true regarding Mr SM serum calcium and phosphorus levels? 1. Both his serum phosphorus and serum calcium levels will be above the normal laboratory range 2. Both his serum phosphorus and serum calcium levels will be below the normal laboratory range 3. His serum phosphorus level will be above the normal laboratory range and his serum calcium level will be below the normal laboratory range 4. His serum phosphorus level will be above the normal laboratory range and his serum calcium level will be within the normal laboratory range
- 13. • Available datademonstrate that among individuals with stage 5D CKD (stage 5 CKD on dialysis) serum calcium levels remain in the normal range and serum phosphorus levels are elevated. • Results were found when examining cross-sectional data from the international Dialysis Outcomes and Practice Pattern Study (DOPPS)
- 15. • Therefore: thecorrect answer is: 4. His serum phosphorus level will be above the normal laboratory range and his serum calcium level will be within the normal laboratory range
- 16. Patient Case 1(cont) • His calcium and phosphorus levels every 3 months and have noted based on several measures that while his serum calcium level is normal, his serum phosphorus level remains persistently above the normal laboratory range. • Which of the following would be the first step in trying to lower Mr Smith's serum phosphorus level? 1. Increase the frequency of dialysis from 3 times to 5 times a week 2. Increase the dialytic phosphate removal 3. Reduce phosphate intake through dietary modifications 4. Start a phosphate binder
- 17. • Adequate controlof serum phosphorus is a cornerstone in the clinical management of patients with CKD because hyperphosphatemia contributes to the pathogenesis of hyperparathyroidism, vascular calcification, and increased cardiovascular mortality. • Interventions include dietary phosphate restriction (first- line), dialysis, and phosphate binders. • So the correct answer is: 3. Reduce phosphate intake through dietary modifications so dietary restriction of phosphorus – restricting the intake of colas, legumes, and dairy products -- is the cornerstone of management.
- 18. Patient Case 1(cont) • Despite dietary modifications aimed to decrease phosphate intake, serum phosphorus level remains elevated. He now requires an intestinal phosphorus binder. • Which of the following statements concerning use of a phosphate binder in this patient is true? 1. Non-calcium-based binders are associated with a decrease in mortality 2. Aluminum hydroxide is safe to use 3. Calcium salts have not been associated with any harm 4. Non-calcium-based binders have no advantage with respect to hard clinical outcomes compared with calcium-based binders
- 19. • Aluminum hydroxideis a potent phosphate binder but is associated with skeletal, neurological, and hematological toxicity. • Calcium salts, specifically calcium carbonate and calcium acetate, are effective in lowering serum phosphorus levels but may cause harm. • It appears that non-calcium-based phosphate binders are associated with less progression of coronary artery calcification and a decrease in mortality, likely due to a decrease in CV deaths. • Therefore the correct answer is: 1. Non-calcium-based binders are associated with a decrease in mortality
- 20. Patient case 1 •Mr SM has now been on dialysis for 1 year. • He is poorly compliant to low phosphorus diet and calcium carbonate, he often skips doses. • His laboratory testing consistently demonstrates a mild elevation in his phosphorus level, a normal serum calcium level, and an elevated serum intact parathyroid hormone (PTH) level. • He is at risk for Vascular complication. • Which of the following interventions would be inappropriate for Mr SM? 1. Refer to a renal dietitian 2. Change from a calcium-based to a non-calcium-based binder 3. Obtain a lateral abdominal radiograph to assess for the presence or absence of vascular calcification 4. Prescribe vitamin K to prevent calcification
- 21. • The prevalenceof vascular calcification increases as kidney function declines. • Vitamin K (through its effects on matrix Gla protein) may inhibit the progression of vascular calcification. • Individuals with ESRD commonly have a vitamin K deficiency. • Of note, while there are 3 randomized controlled trials currently recruiting individuals with CKD to evaluate the effects vitamin K on vascular calcification. • To date there are no data showing that correcting a vitamin K deficiency prevents or improves vascular health in CKD. • As a result, clinical practice guidelines such as those from KDIGO do not recommend routine vitamin K supplementation in individuals with kidney disease.
- 22. • Therefore thecorrect answer is : 4. Prescribe vitamin K to prevent calcification would be inappropriate for Mr SM?
- 23. Case 2 • MsL S is a 29-year-old woman with recently diagnosed lupus nephritis. • She is referred to you for management of her stage 3 CKD (estimated glomerular filtration rate [eGFR]= 35 mL/min). • She is asymptomatic with regard to her lupus. • She does not smoke and attends excercise twice each week. • She is married with a 7-year-old child.
- 24. Case 2 • Whichof the following is most likely to be TRUE regarding Ms LS serum phosphorus level? • Her serum phosphorus level will be above the normal laboratory range • There are no data showing that elevated serum phosphorus levels are associated with any adverse events • Her serum phosphorus level will be below the normal laboratory range • The lower you can get her serum phosphorus level, the lower the prevalence of adverse events in this patient
- 25. The prevalence ofabnormalities in serum phosphorus has been described using cross-sectional data in 1800 individuals with stages 3 to 5 CKD. once eGFR declines to less than 40 mL/min – her eGFR is 35 mL/min -- then serum phosphorus rises.
- 26. • Hyperphosphatemia isan inevitable consequence of decreasing renal function. • Therefore the correct answer is: 1. Her serum phosphorus level will be above the normal laboratory range
- 27. • Which ofthe following statements about Ms West's serum calcium is most likely correct? 1. Her serum calcium level will be below the normal laboratory range 2. Her serum calcium level will be within the normal laboratory range 3. There are no clinical consequences associated with an elevated serum calcium level 4. Her serum calcium level will be above the normal laboratory range
- 28. • The samecross-sectional study also described the prevalence of abnormalities in serum calcium according to stage of CKD • Note that the prevalence of hypocalcemia that increases with declining renal function is exceedingly low -- at most 15% with an EGFR lower than 20 mL/min.
- 29. • The presenceof an abnormal calcium level is unlikely at this stage of kidney disease • So the correct answer is : 2. Her serum calcium level will be within the normal laboratory range
- 30. Case 2 Laboratory testingdemonstrates a serum calcium level of 2.50 mmol/L (within normal laboratory range), a serum phosphorus level of 1.8 mmol/L (above the normal laboratory range), and a PTH of 10.3 pmol/L (above the normal laboratory range). • Based on these laboratory results, which of the following statements is FALSE regarding the next appropriate step for Ms West? 1. Dietary restriction of serum phosphorus would be beneficial 2. In the early stages of CKD dietary restriction of phosphorus may be all that is required 3. Phosphate binders (calcium-based and/or non-calcium- based) have no role in the management of hyperphosphatemia in predialysis CKD 4. Calcium salts are effective phosphate binders
- 31. • phosphate bindersand a phosphorus-restricted diet can be considered in patients with CKD to help keep serum phosphorus levels within the normal range.
- 32. All-cause mortality foreach type of phosphate binder
- 33. • So thecorrect answer is: 3. Phosphate binders (calcium-based and/or non-calcium- based) have no role in the management of hyperphosphatemia in predialysis CKD
- 34. Case 3 • 42-year-oldman who has advanced focal segmental glomerulosclerosis and an estimated glomerular filtration rate (eGFR) of 18 ml/min/1.73m2. • His past medical history includes hypertension and osteoarthritis. He does not smoke or drink alcohol excessively. • Current medications include lisinopril 20 mg daily, amlodipine 10 mg daily, and fish oil. • A previous 6-month trial of high-dose corticosteroids failed to impact the course of his disease and was discontinued. • He plans to receive a living donor kidney from his sister when he reaches end-stage renal disease. • He denies uremic symptoms, including dyspnea, fatigue, anorexia, nausea, pruritus, or swelling. • His exam reveals a body mass index of 27 kg/m2, blood pressure of 147/85 mm Hg, and trace pedal edema. • His serum albumin level is 3.6 g/dL
- 35. Serum calcium 7.8mg/dL (normal range 8.4 to 10.2 mg/dL) Serum phosphate 4.0 mg/dL (normal range 2.5 to 4.5 mg/dL) Serum parathyroid hormone 241 pg/mL (normal range 8 to 65 pg/mL) Serum 25- hydroxyvitamin D 32 ng/mL
- 36. • Which ofthe following is most likely to be responsible for the patient's hypocalcemia and hyperparathyroidism? 1. Phosphate retention 2. Substrate vitamin D deficiency 3. Calcitriol deficiency 4. Parathyroid hormone related peptide 5. Osteoarthritis
- 38. • Chronic kidneydisease leads to impaired phosphate excretion and reduced synthesis of 1,25(OH)2D (calcitriol). • Calcitriol deficiency causes reduced absorption of dietary calcium with a fall in serum calcium concentrations and secondary hyperparathyroidism. • So the correct answer is : 3. Calcitriol deficiency
- 39. • Which ofthe following treatments for mineral metabolism disorders would be most appropriate in this case? • Oral calcitriol 0.25 μg daily • Cholecalciferol 2,000 IU daily • Ergocalciferol 50,000 IU weekly • Calcium carbonate 1200 mg daily • Diltiazem 360 mg daily
- 40. • Calcitriol, thehormonally active form of vitamin D3 will most effectively affect this patient's reduced synthesis of 1,25(OH)2D and thereby correct his low calcium levels and secondary hyperparathyroidism. • Serum 25-hydroxyvitamin D is 32 ng/mL within normal. • So the correct answer is: • Oral calcitriol 0.25 μg daily
- 41. • You initiatetreatment with oral calcitriol 0.25 μg per day. Which of the following should be checked within the next 3 months? 1. Serum 25-hydroxyvitamin D 2. Serum magnesium 3. Serum parathyroid hormone 4. Urine fractional excretion of phosphate 5. Serum calcium and phosphate
- 42. • Calcitriol increasesgastrointestinal absorption of calcium and phosphate through different receptors. Increased levels of these minerals can be noted hours to days after treatment initiation. • The correct answer: 5. Serum calcium and phosphate
- 43.