At the monthly quality assurance meeting of your dialysis
unit, you are shown chemical analysis results for the past 2 months (nd=not
detectable):
–October 2011 (mg/L)
• Aluminum 0.01, Copper nd, Zinc nd, Na 200,
Chloramines 0.75, fluoride 0.5,
sulfate nd
– September 2011
(mg/L)
• Aluminum nd, Copper nd, Zinc nd, Na 147, Chloramines nd, fluoride nd, sulfate nd
What should you do?
__________________
The answer to the dialysis quiz from October 24, 2011 is E.
A 72-year-old diabetic man has been on hemodialysis for 8 years. He has been stable on dialysis. He has had problems with phosphorus control that have required close dietary counslling. He denies bone pain. He dialyzes on a 2.5 meq/L Calcium bath, and a recent Kt/V was 1.54. Medications include calcium acetate 667 mg, two tabs with each meal, and calcitriol 4 µg at each dialysis treatment. Laboratory studies: sodium 139 mEq/L, potassium 4.9 mEq/L, chloride 99 mEq/L, bicarbonate 20 mEq/L, calcium 10.2 mg/dL, and phosphorus 6.9 mg/dL, intact parathyroid hormone (iPTH) 40 pg/mL, 25(OH) D 47 ng/ml.
Which of the following statements represents appropriate management of this patient?
A.) The patient should continue on his present medications. No changes are needed.
B.) The patient’s calcitriol dose should be doubled
C.) Calcium acetate should be stopped in 3 months if his PTH is < 100 pg/ml.
D.) The patient should be started on a low dose of paricalcitol to reduce the risk of a cardiovascular event or death.
E.) The patient should stop his calcitriol and calcium acetate and sevelamer 1600 mg TID started.
Explanation
The patient has a calcium x phosphorus product >55. Continuing either or both calcitriol and calcium acetate will exacerbate this problem, whereas substituting with sevelamar will reduce phosphorus through gastrointestinal binding of phosphorus without an associated increase in calcium. There is more information on sevelemar on the link. Fig.1 shows data from an early study on the effectiveness of sevelemar in reducing phosphorus.
Explanation
The patient has a calcium x phosphorus product >55. Continuing either or both calcitriol and calcium acetate will exacerbate this problem, whereas substituting with sevelamar will reduce phosphorus through gastrointestinal binding of phosphorus without an associated increase in calcium. There is more information on sevelemar on the link. Fig.1 shows data from an early study on the effectiveness of sevelemar in reducing phosphorus.
