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.

CaCO3 & CALCITRIOL PROTOCOL IN HD Presented by: Dr Faraz Niaz Consultant May 2008

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 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.

iPTH PTH Target 16 – 33 pmol/L ( pg/ml) Evaluation Every 3 Months

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)

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 33

Normal physiological dose 1µg/day

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( ). 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) ( mg/dl). D/C Calcitriol for frank hypercalcemia ( >2.63mmol/L) or 10.5mg/dl) After resolution of hypercalcemia restart Calcitriol

PTH pmol/L Dose/ HD of Calcitriol 33 – 60 Oral / IV: 0.5 – 1.5 µg 60 – 100 Oral:1– 4 µg & IV:1 – 3 µg > 100 Oral:3 – 7µg &IV: 3 – 5µg

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

Indications for Parathyroidectomy by DOQI Severe hyperparathyroidism refractory to medical therapy 1. PTH >800 pmol/l (88 pg/ml) &/or ↑ Ca & > ↑ P 2. Calciphylaxis with PTH > 500pmol/L ( 55pg/ml )

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 >0.5 cm

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

POST- Parathyroidectomy protocol Measure Ca every 4 – 6 hrs for 48 to 72 hrs. If ionized Ca is <0.9 mmol/L (3.6 mg/dl) or Corrected Ca <1.8 mmol/L(7.2) Start Ca infusion 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 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 ( mg/dl)