This lecture was conducted during the Nephrology Unit Grand Ground by Consultant under Nephrology Di

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• This lecture was conducted during the Nephrology
  Unit Grand Ground by Consultant under Nephrology
  Division under the supervision and administration
  of Prof. Jamal Al Wakeel, Head of Nephrology
  Unit, Department of Medicine and Dr. Abdulkareem
  Al Suwaida, Chairman of the Department of
  Medicine. Nephrology Division is not responsible
  for the content of the presentation for it is
  intended for learning and /or education purpose
  only.

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CaCO3 CALCITRIOL PROTOCOL IN HD

• Presented by
• Dr Faraz Niaz
• Consultant
• May 2008

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CALCIUM

• Evaluation Monthly
• Daily intake should not be gt 2000 mg/day (eg
  1500 from P-binders 500 from diet )
• 
  
• Target Low normal preferred 2.1 2.4 mmol/L
  
• (corrected
  (8.4 9.5 mg/dl)
• If gt 2.55 mol/L(10.2mg/dl),
• change to Non-Ca binders,
  ? Vit D
  or
• change to low Ca-dialysate

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PHOSPHORUS

• Evaluation Monthly
• Daily intake (adjusted to protein intake) 800
  1000mg/day
• Phosphate/ gram of protein 12 16 mg.
• Target 1.13 - 1.78 mmol/L
• (3.5 5.5 mg/dl)

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PHOSPHATE BINDERS

• Start when P or PTH gt Target
• Use CaCO3 or/and non-Ca binder(Sevelamer
  
  Limit Ca intake from binders to 1500mg/day.
• 1.CaCO3 upto 600 mg BD with food
• 2.Sevelamer (Renagel) 800 mg with meals(?upto 2
  tab TID
• Stop Ca-binder if Ca gt2.55 mmol/L or PTH lt 15
• Aluminum binder may be used for short term
• (up to 4 wks) if P gt2.33 ( 7.0 mg/dl), for
  one course.
• In such pt, consider more frequent dialysis.

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iPTH

• PTH Target 16 33 pmol/L
• (150-300 pg/ml)
• Evaluation Every 3 Months

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Vitamin D (Calcitriol)

• Start if PTH gt 33 pmol/L (
  300 pg/ml)
• Ca lt 2.4 mmol/l
  ( 6.5 mg/dl)
• P lt 1.8 mmol/l
  ( 5.5 mg/dl)
• Ca x P lt 4.4 ( 55
  mg/dl²)
• Hold Calcitriolwhen PTH lt 15 pmol/L(150 pglml)
• Ca gt 2.55 mmol/L
  (10.2 mg/dl)
• P gt 1.8
  mmol/L (1.8 pg/dl)

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When to change the dose of Calcitriol

• If decrease in PTH is gt 50 after 4 wks of
  initiation, then decrease dose to half.
• If Calcitriol was held as PTH had decreased to lt
  16, restart at half the dose when PTH gt 33

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Normal physiological dose

• 1µg/day

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IV Dose Regimens

• Calcitriol can be started at dose of 0.5 µg
  titrated upward to 2.0 µg at end of each HD
  depending upon PTH levels.
• Dose of Calcitriol should be titrated to raise Ca
  level to approx 2.4 2.55mmol/L(9.6-10.2).
• NOTE Total Ca should be ? to levels required to
  suppress PTH to desired levels while avoiding
  hypercalcemia.
• Calcitriol dose should be reduced by 50 or
  stopped with Ca levels at the upper normal range
  or with mild hypercalcemia ( 2.5 2.63mmol/L)
  (10.0- 10.5mg/dl).
• D/C Calcitriol for frank hypercalcemia (
  gt2.63mmol/L) or 10.5mg/dl)
• After resolution of hypercalcemia restart
  Calcitriol

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• PTH pmol/L Dose/ HD of Calcitriol
• 33 60 Oral / IV 0.5 1.5 µg
• 60 100 Oral1 4 µg IV1 3 µg
• gt 100 Oral3 7µg IV 3 5µg

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• PD pts may receive Oral Calcitriol 0.5 1.0 µg
  2 to 3 times/week.
• A lower dose of 0.25 mcg may be given daily

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Indications for Parathyroidectomy by DOQI

• Severe hyperparathyroidism refractory to medical
  therapy
• 1. PTH gt800 pmol/l (88 pg/ml)
• /or ? Ca gt ? P
• 2. Calciphylaxis with PTH gt 500pmol/L
• (
  55pg/ml )

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Other Indications for Parathyroidectomy

• Intractable pruritis with ? PTH
• Recurrent need of with holding Vit D due to ? Ca
  or P
• Gland size by USD or CT Scan 0.5 cm or volume
  gt0.5 cm

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DOQI recommends

• Pre-op parathyroid imaging (USD, CT, MRI, MIBI
  Scan) is usually not required, but may be used if
  recurrent hyperparathyroidism

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POST- Parathyroidectomy protocol

• Measure Ca every 4 6 hrs for 48 to 72 hrs.
• If ionized Ca is lt0.9 mmol/L (3.6 mg/dl) or
• Corrected Ca lt1.8 mmol/L(7.2)
• Start Ca infusion IV _at_ 1 2 mg/kg/hr. of
  elemental Ca
• (10 ampoules of 10 calcium gluconate (10ml each)
  contain 90 mg of elemental Ca)
• Decrease Ca infusion gradually when ionized Ca is
  normal stable.
• Oral CaCO3 can be given _at_ 1- 2 Gm TID
• Calcitriol upto 2 µg/day
• Adjust these to keep ionized Ca in normal range
  of
• 1.16 1.32 mmol/L (4.65 - 5.28mg/dl)