Med j club nejm op bs.
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Med j club nejm op bs.

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Med j club nejm op bs. Med j club nejm op bs. Presentation Transcript

  • Dr.Mohammad Shaikhani. CABM/FRCP
  • Hyperphosphataemia The Silent Killer Amann K, Gross ML, London GM, Ritz E: Hyperphosphatemia - a silent killer of patients with uremia. NDT , 1999,14,2085-2087 .
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  • Metastatic Calcification & Ossification
    • Amorphous
    • (CaMg) 3 (PO 4 ) 2
    • Soft tissue
      • Heart
      • Lungs
      • Kidneys
    • Hydroxyapatite
    • Ca 10 (PO 4 ) 6 (OH) 2
    • Vascular
    • Valvular
    • Joints
    • Ocular
    Calcium and phosphate are deposited in one of two forms;
  • CALCIUM
    • Evaluation Monthly
    • Daily intake should not be > 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 > 2.55 mol/L(10.2mg/dl),
    • change to Non-Ca binders , ↓ Vit D or
    • change to low Ca-dialysate
  • 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)
  • PHOSPHATE BINDERS
    • Start when P or PTH > 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 >2.55 mmol/L or PTH < 15
    • Aluminum binder may be used for short term
    • (up to 4 wks) if P >2.33 ( 7.0 mg/dl), &for one course.
    • In such pt, consider more frequent dialysis .
  • PHOSPHATE BINDERS
    • Start when P or PTH > 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 >2.55 mmol/L or PTH < 15
    • Aluminum binder may be used for short term
    • (up to 4 wks) if P >2.33 ( 7.0 mg/dl), &for one course.
    • In such pt, consider more frequent dialysis .
  • Vitamin D (Calcitriol) Start if PTH > 33 pmol/L ( 300 pg/ml) Ca < 2.4 mmol/l ( 6.5 mg/dl) P < 1.8 mmol/l ( 5.5 mg/dl) Ca x P < 4.4 ( 55 mg/dl²) Hold Calcitriol:when PTH < 15 pmol/L(150 pglml) Ca > 2.55 mmol/L (10.2 mg/dl) P > 1.8 mmol/L (1.8 pg/dl)
  • iPTH
    • PTH Target 16 – 33 pmol/L
    • (150-300 pg/ml)
    • Evaluation Every 3 Months
  • When to change the dose of Calcitriol
    • If decrease in PTH is > 50% after 4 wks of initiation, then decrease dose to half.
    • If Calcitriol was held as PTH had decreased to < 16, restart at half the dose when PTH > 33
  • Characteristics of an Ideal Oral Phosphate Binder
    • High affinity for binding phosphorous - low dose required
    • Rapid phosphate binding
    • Low solubility
    • Low systemic absorption (preferably none)
    • Non toxic
    • Solid oral dose form
    • Palatable - encourages compliance
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    • magnesium iron hydroxycarbonate (fermagate): 1 g given 3 times a day before meals reduces serum phosphate, but dose (6 g/ day) was associated with adverse GIT events.
    • MCI-196 (colestilan), a novel nonmetallic anion-exchange resin (similar to sevelamer), was associated with reductions in phosphate of 0.2 mmol per liter.
    • Niacin/nicotinamide,associated with a significant reduction in serum phosphate levels, through direct inhibition of the sodium-dependent phosphate cotransporter Na-Pi-2b in GIT.
    • MCI-96, niacin, and nicotinamide also lower serum cholesterol & triglyceride-rich lipoproteins.