MAKATI MEDICAL CENTERMAKATI MEDICAL CENTERDEPARTMENT OF MEDICINEDEPARTMENT OF MEDICINE

MEDICAL GRANDROUNDSMEDICAL GRANDROUNDS

Ma. Melmar S. Anicoche, M.D.Ma. Melmar S. Anicoche, M.D.April 29, 2010April 29, 2010

Objectives Objectives

1. To discuss the effect of Chronic Kidney Disease (CKD) on calcium-phosphorus metabolism.

2. To discuss biochemical complications after parathyroidectomy.

Patient Profile Patient Profile

L.G. , 61/F, from Binan, Laguna

DOA: February 12, 2010

Chief complaint: Persistently elevated PTH

History of Present IllnessHistory of Present Illness

2 years PTA2 years PTA

1 year PTA1 year PTA

Bone pains, weakness, Bone pains, weakness, intermittent abdominal painintermittent abdominal pain

iPTH: 914.218 (15-65pg/ml)iPTH: 914.218 (15-65pg/ml) Normal calcium, elevated Normal calcium, elevated

phosphorusphosphorus Impression: tertiary Impression: tertiary

hyperparathyroidismhyperparathyroidism

iPTH: 1,528 pg/mliPTH: 1,528 pg/ml

Patient is a diagnosed case of End stage Renal Disease since 2000, on hemodialysis since 2001, three times a week.

Admission

Review of Systems: (-) weight loss, headache, fever, vomiting, chest pain, bowel movement irregularities

Past Medical History:s/p Bilateral Ureterolithotomy – 1995s/p Nephrectomy,left – 1998s/p ESWL, right – 2000s/p CVA – 2000 & 2007

Family History: (+) Urolithiasis – parents & siblings

Personal & Social History: Nonsmoker Nonalcoholic beverage drinker

BP: 140/70 CR 74 bpm, regular RR 20 cpm T 36.5°C

Warm moist skin, no active dermatoses

Pink palpebral conjunctivae, anicteric sclerae

Supple neck, no palpable lymph nodes, thyroid not enlarged, no masses

Symmetric chest expansion, no retractions, clear breath sounds

,AB at 5th LICS MCL, S1 louder than S2 at the apex, S2 louder than S1 at the base, no murmurs

Flabby abdomen (+) 9cm incisional scar on left lower quadrant, (+) 6 cm incisional scar on right lower quadrant, NABS, soft, nontender, no organomegaly

Full and equal pulses, No cyanosis & edema of extremities

MMT: 5/5 on left lower extremity & both upper & lower extremities, 3/5 left upper extremity; slight limitation of motion on all extremities

Salient Features

61/F61/FKnown case of End Stage Renal Disease Known case of End Stage Renal Disease

for 10 years, on hemodialysisfor 10 years, on hemodialysisBone pains, weakness and abdominal Bone pains, weakness and abdominal

painpainElevated iPTH & phosphorus, normal Elevated iPTH & phosphorus, normal

calciumcalcium

Impression: Tertiary HyperparathyroidismImpression: Tertiary Hyperparathyroidism

Reduced GFR

Reduced action of 1,25 (OH) 2D Phosphate retention

Vitamin D resistant stateInterference with

production of 1,25 (OH) 2D by kidneys

Increased need for Vitamin D

Relative or absolute deficiency of 1,25 (OH) 2D3

Normal or low blood levels of 1,25 (OH) 2D

Decreased intestinal absorption

of Ca

Hypocalcemia

Skeletal resistance

to PTH action

Secondary Hyperparathyroidism

Decreased expression of VDR

in parathyroid

Rickets or osteomalaci

aBone resorption (Osteitis fibrosa

cystica)

Decreased expression of Ca-sensing receptor in parathyroid

K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease

Frequency of Measurement of iPTH, Ca & Phos

CKD Stage GFR Range iPTH Ca & Phos

3 30 – 59 Every 12 months

Every 12 months

4 15 – 29 Every 3 months

Every 3 months

5 <15 or dialysis

Every 3 months

Every month

K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease

Target Range of iPTH, Ca & PhosCKD Stage iPTH

(pg/ml)Ca (mg/dl) Phos

(mg/dl)

3 35 – 70 8.6 – 10.2 2.7 – 4.6

4 70 – 110 8.6 – 10.2 2.7 – 4.6

5 150 - 300 8.4 – 9.5 3.5 – 5.5

K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease

Outpatient Labs

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Mar

May Ju

lySe

ptNov Ja

n

CalciumPhosphorus

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10

12

1stHD

2ndHD

3rdHD

4thHD

5thHD

6thHD

CalciumPhosphorusPTH

1000

800

600

400

200

Day of Surgery

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0000H 1500H 2300H

Calcium

Potassium

Vitamin D

Patients on HD or PD with iPTH >300pg/ml

Elevated corrected serum calcium and/or phosphorus levels

Hyperparathyroidism

Characterized by excessive secretion of PTHPrimarySecondaryTertiary

Symptoms are due to the hypercalcemia itself

Treatment Options

MedicalSurgical

Phosphate Binders

phosphorus or iPTH levels not controlled despite phosphorus restriction

Calcium-based

Noncalcium, nonaluminum, nonmagnesium containing

Vitamin D

Patients on HD or PD with iPTH >300pg/ml

Elevated corrected serum calcium and/or phosphorus levels

Calcimimetic Drugs

Activate the calcium-sensing receptor and inhibit parathyroid cell function

Results in reduction without normalization of PTH levels

Reduction & normalization of calciumCinacalcet

Treatment Options (Surgical)

Subtotal or total parathyroidectomy, with or without parathyroid tissue autotransplantation

Ablation of parathyroid tissue by direct injection of alcohol

Kidney transplantation

Parathyroidectomy in Patients with CKD

persistent iPTH >800 pg/mL associated with hypercalcemia and/or hyperphosphatemia that are refractory to medical therapy

iCa measured every 4 to 6 hours for the first 48 to 72 hours after surgery, and then twice daily until stable.

Criteria for adequate excision 50% drop in PTH from the baseline level to the 10-minute

postexcision level or 50% drop in PTH from the preexcision level at 10 minutes and a

postexcision level below the baseline level.

Surgical Complications after Parathyroidectomy

Nerve damageBleedingInfection

Biochemical Aberrations in a Dialysis Patient Following Parathyroidectomy

Severe hypocalcemia hypophosphatemia hyperkalemia.

Cruz, Dinna, et. Al.;American Journal of Kidney Disease, vol 29, No 5 (May) 1997; pp759 - 762

Hungry Bone Syndrome

Severe post-operative hypocalcemia despite normal or elevated PTH

Occurs in patients who have developed bone disease preoperatively due to a chronic increase in bone resorption induced by high PTH

Diagnosis of Hungry Bone Syndrome

Persistently low serum calcium following parathyroidectomy

Low or low normal serum phosphateRising/raised serum alkaline phosphataseLow urine calcium

Treatment

Elemental CalciumCalcium gluconateCalcium carbonate

Vitamin D

Can Pamidronate Prevent Hungry Bone Syndrome After parathyroidectomy?

Bisphosphonates may be beneficial in preventing hungry bone syndrome by reducing bone formation

Yuriy Gurevich, DO, and Leonid Poretsky, MD:Can Pamidronate Prevent Hungry Bone Syndrome after Parathyroidectomy, a case report

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1st F

f-up

3rd Ff-u

p

5th Ff-u

p

7th Ff-u

p

9th Ff-u

p

11th

Ff-u

p

CalciumPhosphorus

Current Status of the Patient:

On Dialysis thrice a week On maintenance medicationsStill no match for kidney transplant

Thank You!