Dr.Mohammad Shaikhani. CABM/FRCP
Hyperphosphataemia The Silent Killer Amann K, Gross ML, London GM, Ritz E: Hyperphosphatemia - a silent killer of patients...
 
 
 
 
 
Metastatic Calcification & Ossification <ul><li>Amorphous </li></ul><ul><li>(CaMg) 3 (PO 4 ) 2 </li></ul><ul><li>Soft tiss...
CALCIUM   <ul><li>Evaluation  Monthly  </li></ul><ul><li>Daily intake  should not be > 2000 mg/day  (eg 1500  from P-binde...
PHOSPHORUS <ul><li>Evaluation  Monthly </li></ul><ul><li>Daily intake (adjusted to protein intake)  800 – 1000mg/day </li>...
PHOSPHATE BINDERS <ul><li>Start when P or PTH  > Target   </li></ul><ul><li>Use CaCO3 or/and non-Ca binder(Sevelamer  Limi...
PHOSPHATE BINDERS <ul><li>Start when P or PTH  > Target   </li></ul><ul><li>Use CaCO3 or/and non-Ca binder(Sevelamer  Limi...
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/d...
iPTH <ul><li>PTH  Target  16 – 33 pmol/L  </li></ul><ul><li>(150-300 pg/ml) </li></ul><ul><li>Evaluation  Every 3 Months  ...
When to change the dose of Calcitriol <ul><li>If  decrease in PTH is > 50% after 4 wks of initiation, then decrease dose t...
Characteristics of an Ideal Oral Phosphate Binder <ul><li>High affinity for binding phosphorous  - low dose required </li>...
 
 
 
<ul><li>magnesium iron hydroxycarbonate (fermagate): 1 g given 3 times a day before meals reduces serum phosphate, but dos...
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Med j club nejm op bs.

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Med j club nejm op bs.

  1. 1. Dr.Mohammad Shaikhani. CABM/FRCP
  2. 2. 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 .
  3. 8. Metastatic Calcification & Ossification <ul><li>Amorphous </li></ul><ul><li>(CaMg) 3 (PO 4 ) 2 </li></ul><ul><li>Soft tissue </li></ul><ul><ul><li>Heart </li></ul></ul><ul><ul><li>Lungs </li></ul></ul><ul><ul><li>Kidneys </li></ul></ul><ul><li>Hydroxyapatite </li></ul><ul><li>Ca 10 (PO 4 ) 6 (OH) 2 </li></ul><ul><li>Vascular </li></ul><ul><li>Valvular </li></ul><ul><li>Joints </li></ul><ul><li>Ocular </li></ul>Calcium and phosphate are deposited in one of two forms;
  4. 9. CALCIUM <ul><li>Evaluation Monthly </li></ul><ul><li>Daily intake should not be > 2000 mg/day (eg 1500 from P-binders & 500 from diet ) </li></ul><ul><li>Target: Low normal preferred : 2.1 – 2.4 mmol/L </li></ul><ul><li>(corrected (8.4 – 9.5 mg/dl) </li></ul><ul><li>If > 2.55 mol/L(10.2mg/dl), </li></ul><ul><li>change to Non-Ca binders , ↓ Vit D or </li></ul><ul><li>change to low Ca-dialysate </li></ul>
  5. 10. PHOSPHORUS <ul><li>Evaluation Monthly </li></ul><ul><li>Daily intake (adjusted to protein intake) 800 – 1000mg/day </li></ul><ul><li>Phosphate/ gram of protein : 12 – 16 mg. </li></ul><ul><li>Target 1.13 - 1.78 mmol/L </li></ul><ul><li>(3.5 – 5.5 mg/dl) </li></ul>
  6. 11. PHOSPHATE BINDERS <ul><li>Start when P or PTH > Target </li></ul><ul><li>Use CaCO3 or/and non-Ca binder(Sevelamer Limit Ca intake from binders to 1500mg/day. </li></ul><ul><li>1.CaCO3 upto 600 mg BD with food </li></ul><ul><li>2.Sevelamer (Renagel) 800 mg with meals(↑upto 2 tab TID </li></ul><ul><li>Stop Ca-binder if Ca >2.55 mmol/L or PTH < 15 </li></ul><ul><li>Aluminum binder may be used for short term </li></ul><ul><li>(up to 4 wks) if P >2.33 ( 7.0 mg/dl), &for one course. </li></ul><ul><li>In such pt, consider more frequent dialysis . </li></ul>
  7. 12. PHOSPHATE BINDERS <ul><li>Start when P or PTH > Target </li></ul><ul><li>Use CaCO3 or/and non-Ca binder(Sevelamer Limit Ca intake from binders to 1500mg/day. </li></ul><ul><li>1.CaCO3 upto 600 mg BD with food </li></ul><ul><li>2.Sevelamer (Renagel) 800 mg with meals(↑upto 2 tab TID </li></ul><ul><li>Stop Ca-binder if Ca >2.55 mmol/L or PTH < 15 </li></ul><ul><li>Aluminum binder may be used for short term </li></ul><ul><li>(up to 4 wks) if P >2.33 ( 7.0 mg/dl), &for one course. </li></ul><ul><li>In such pt, consider more frequent dialysis . </li></ul>
  8. 13. 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)
  9. 14. iPTH <ul><li>PTH Target 16 – 33 pmol/L </li></ul><ul><li>(150-300 pg/ml) </li></ul><ul><li>Evaluation Every 3 Months </li></ul>
  10. 15. When to change the dose of Calcitriol <ul><li>If decrease in PTH is > 50% after 4 wks of initiation, then decrease dose to half. </li></ul><ul><li>If Calcitriol was held as PTH had decreased to < 16, restart at half the dose when PTH > 33 </li></ul>
  11. 16. Characteristics of an Ideal Oral Phosphate Binder <ul><li>High affinity for binding phosphorous - low dose required </li></ul><ul><li>Rapid phosphate binding </li></ul><ul><li>Low solubility </li></ul><ul><li>Low systemic absorption (preferably none) </li></ul><ul><li>Non toxic </li></ul><ul><li>Solid oral dose form </li></ul><ul><li>Palatable - encourages compliance </li></ul>
  12. 20. <ul><li>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. </li></ul><ul><li>MCI-196 (colestilan), a novel nonmetallic anion-exchange resin (similar to sevelamer), was associated with reductions in phosphate of 0.2 mmol per liter. </li></ul><ul><li>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. </li></ul><ul><li>MCI-96, niacin, and nicotinamide also lower serum cholesterol & triglyceride-rich lipoproteins. </li></ul>

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