MAKATI MEDICAL CENTER DEPARTMENT OF MEDICINE MEDICAL GRANDROUNDS Ma. Melmar S. Anicoche, M.D. April...
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Transcript of MAKATI MEDICAL CENTER DEPARTMENT OF MEDICINE MEDICAL GRANDROUNDS Ma. Melmar S. Anicoche, M.D. April...
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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
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Objectives Objectives
1. To discuss the effect of Chronic Kidney Disease (CKD) on calcium-phosphorus metabolism.
2. To discuss biochemical complications after parathyroidectomy.
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Patient Profile Patient Profile
L.G. , 61/F, from Binan, Laguna
DOA: February 12, 2010
Chief complaint: Persistently elevated PTH
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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
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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
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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
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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
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Impression: Tertiary HyperparathyroidismImpression: Tertiary Hyperparathyroidism
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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
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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
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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
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Outpatient Labs
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Jan
Mar
May Ju
lySe
ptNov Ja
n
CalciumPhosphorus
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1stHD
2ndHD
3rdHD
4thHD
5thHD
6thHD
CalciumPhosphorusPTH
1000
800
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400
200
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Day of Surgery
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0000H 1500H 2300H
Calcium
Potassium
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Vitamin D
Patients on HD or PD with iPTH >300pg/ml
Elevated corrected serum calcium and/or phosphorus levels
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Hyperparathyroidism
Characterized by excessive secretion of PTHPrimarySecondaryTertiary
Symptoms are due to the hypercalcemia itself
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Treatment Options
MedicalSurgical
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Phosphate Binders
phosphorus or iPTH levels not controlled despite phosphorus restriction
Calcium-based
Noncalcium, nonaluminum, nonmagnesium containing
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Vitamin D
Patients on HD or PD with iPTH >300pg/ml
Elevated corrected serum calcium and/or phosphorus levels
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Calcimimetic Drugs
Activate the calcium-sensing receptor and inhibit parathyroid cell function
Results in reduction without normalization of PTH levels
Reduction & normalization of calciumCinacalcet
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Treatment Options (Surgical)
Subtotal or total parathyroidectomy, with or without parathyroid tissue autotransplantation
Ablation of parathyroid tissue by direct injection of alcohol
Kidney transplantation
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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.
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Surgical Complications after Parathyroidectomy
Nerve damageBleedingInfection
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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
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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
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Diagnosis of Hungry Bone Syndrome
Persistently low serum calcium following parathyroidectomy
Low or low normal serum phosphateRising/raised serum alkaline phosphataseLow urine calcium
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Treatment
Elemental CalciumCalcium gluconateCalcium carbonate
Vitamin D
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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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0
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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
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Current Status of the Patient:
On Dialysis thrice a week On maintenance medicationsStill no match for kidney transplant
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Thank You!