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Ca++, PO4, PTH & VIT D. Calcium, Phosphorus & Vitamin D In Chronic Renal Failure By Dr. Rick Hiller. Phosphorus Measurement and Balance. Normal concentration between 2.5 and 4.5 mg/dl.

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Ca po4 pth vit d

Ca++, PO4, PTH & VIT D

Calcium, Phosphorus & Vitamin D

In Chronic Renal Failure

By Dr. Rick Hiller


Phosphorus measurement and balance
Phosphorus Measurement and Balance

  • Normal concentration between 2.5 and 4.5 mg/dl.

  • 85% of total body stores are contained in bone (hydroxyapatite), 14% is intracellular, and 1% extracellular.


Phosphorus measurement and balance1
Phosphorus Measurement and Balance

  • 70% of the extracellular phosphorus is organic (phospholipids) and the remaining 30% is inorganic.

  • 15% of the inorganic is protein bound; the remaining is complexed with sodium, magnesium, or calcium or circulates as free monohydrogen or dihydrogen forms.

  • This freely circulating phosphorus is what is measured.


Phosphorus measurement and balance2
Phosphorus Measurement and Balance

  • 2/3 of ingested phosphorus is excreted in urine; the remaining in stool.

  • Foods high in phosphorus are also high in protein.

  • Three organs are involved in phosphate homeostasis: intestine, kidney, and bone.

  • Major hormones involved are Vit. D and PTH


Phosphorus homeostasis
Phosphorus Homeostasis

  • 60-70% of dietary phosphorus is absorbed by the GI tract via:

    • Passive transport

    • Active transport stimulated by calcitriol and PTH

  • Antacids, phosphate binders, and calcium bind to phosphorus, decreasing the free amount available for absorption


Phosphorus homeostasis1
Phosphorus Homeostasis

  • Inorganic phosphorus is freely filtered by the glomerulus.

  • 70-80% is then reabsorbed in the proximal tubule. The remaining is reabsorbed in the distal tubule.

  • Phosphorus excretion can be increased primarily by increasing plasma phosphorus concentration and PTH.


Phosphorus homeostasis2
Phosphorus Homeostasis

  • Phosphorus excretion can also be increased to a lesser degree by volume expansion, metabolic acidosis, glucocorticoids, and calcitonin.

  • This regulation occurs in the proximal tubule via the sodium-phosphate cotransporter.


Calcium measurement and balance
Calcium Measurement and Balance

  • Normal Concentration between 8.5 and 10.5 mg/dL

  • Serum levels are 0.1-0.2% of extracellular calcium; this is only 1% of total body calcium

  • The remainder of total body calcium is stored in bone.


Calcium measurement and balance1
Calcium Measurement and Balance

  • Ionized calcium is physiologically active and is 40% of total serum calcium.

  • Non-ionized calcium is bound to albumin, citrate, bicarbonate, and phosphate

  • Ionized calcium can be corrected from total calcium by adding 0.8 mg/dL for every 1 mg decrease in serum albumin below 4 mg/dL


Calcium measurement and balance2
Calcium Measurement and Balance

  • PTH regulates serum ionized calcium by

    • Increasing bone resorption

    • Increasing renal calcium reabsorption

    • Increasing the conversion of 25(OH)D to 1,25(OH)2D in the kidney which increases the GI absorption of calcium


Calcium measurement and balance3
Calcium Measurement and Balance

  • Decreased PTH and Vit. D maintain protection against calcium overload by increasing renal excretion and reducing intestinal absorption.


Calcium homeostasis
Calcium Homeostasis

  • Calcium absorption primarily occurs in the duodenum through Vit. D dependent and Vit. D independent pathways.

  • 60-70% of calcium is reabsorbed passively in the proximal tubule, with another 10% reabsorbed in the thick ascending limb


Calcium sensing receptor
Calcium-Sensing Receptor

  • Expressed in organs controlling calcium homeostasis: parathyroid gland, thyroid C cells, intestines, and kidneys.

  • Expression is regulated by 1,25(OH)2D


Synthesis and measurement of vitamin d
Synthesis and Measurement of Vitamin D

  • Vitamin D3 is metabolized in the skin from 7-dehydrocholesterol

  • Vitamin D2 (ergocalciferol) is obtained in the diet from plant sources

  • Vitamin D3 (cholecalciferol) is also obtained in the diet from animal sources


Synthesis and measurement of vitamin d1
Synthesis and Measurement of Vitamin D

  • In the Liver, Vitamins D2 and D3 are hydroxylated to 25(OH)D (calcidiol)

  • Calcidiol then travels to the kidney where it is converted to 1,25(OH)2D


Physiologic effects of vitamin d
Physiologic Effects of Vitamin D

  • Facilitates the uptake of calcium in the intestinal and renal epithelium

  • Enhances the transport of calcium through and out of cells

  • Is important for normal bone turnover


Physiologic effects of vitamin d1
Physiologic Effects of Vitamin D

  • Elevated serum PTH increases the hydroxylation of Vitamin D in the kidney

  • This causes a rise in serum calcium and feeds back to the parathyroid gland decreasing PTH secretion


Regulation and biologic effects of parathyroid hormone
Regulation and Biologic Effects of Parathyroid Hormone

  • Primary function of PTH is to maintain calcium homeostasis by:

    • Increasing bone mineral dissolution

    • Increasing renal reabsorption of calcium and excretion of phosphorus

    • Increasing activity of renal 1-α-hydroxylase

    • Enhancing GI absorption of calcium and phosphorus


Regulation of parathyroid hormone
Regulation of Parathyroid Hormone

  • Hypocalcemia is more important in stimulating PTH release

  • Normal or elevated Calcitriol is more important in inhibiting PTH release


Regulation of parathyroid hormone1
Regulation of Parathyroid Hormone

  • Increased PTH in Secondary Hyperparathyroidism is due to:

    • Loss of renal mass

    • Low 1,25(OH)2D

    • Hyperphosphatemia

    • Hypocalcemia

    • Elevated FGF-23


Measurement of pth
Measurement of PTH

  • Plasma PTH levels provide:

    • a noninvasive way to initially diagnose renal bone disease

    • Allow for monitoring of the disorder

    • Provide a surrogate measure of bone turnover in patients with CKD


Effects of ckd
Effects of CKD

  • Chronic Renal Failure disrupts homeostasis by:

    • Decreasing excretion of phosphate

    • Diminishing the hydroxylation of 25(OH)D to calcitriol

    • Decreasing serum calcium

  • Leads to Secondary Hyperparathyroidism


Secondary hpt
Secondary HPT

  • Initially, the hypersecretion of PTH is appropriate to normalize plasma Ca2+ and phosphate concentrations.

  • Chronically, it becomes maladaptive, reducing the fraction of filtered phosphate that is reabsorbed from 80-95% to 15%


Secondary hpt1
Secondary HPT

  • Secondary HPT begins when the GFR declines to <60 ml/min/1.73m2

  • Serum Ca2+ and PO4 levels remain normal until GFR declines to 20 ml/min/1.73m2

  • Low levels of calcitriol occur much earlier, possibly even before elevations in iPTH.


Secondary hpt2
Secondary HPT

  • Secondary HPT tries to correct:

    • hypocalcemia by increasing bone resorption

    • Calcitriol deficiency by stimulating 1-hydroxylation of calcidiol (25-hydroxyvitamin D) in the proximal tubule


Hypocalcemia
Hypocalcemia

  • Total Serum Calcium usually decreases during CKD due to:

    • Phosphate retention

    • Decreased calcitriol level

    • Resistance to the calcemic actions of PTH on bone


Hypocalcemia1
Hypocalcemia

  • Potent stimulus to the release of PTH

    • Increases mRNA levels via posttranscription

    • Stimulates proliferation of parathyroid cells

  • Plays a predominant role via CaSR:

  • Major therapeutic target for suppressing parathyroid gland function


Decreased vitamin d
Decreased Vitamin D

  • Decreases calcium and phosphorus absorption in the GI tract.

  • Directly increases PTH production due to the absence of the normal suppressive effect of calcitriol

  • Indirectly increases secretion of PTH via the GI mediated hypocalcemic stimulus


Decreased vitamin d1
Decreased Vitamin D

  • Administering calcitriol to normalize plasma levels can prevent or reverse secondary HPT

  • Calcitriol deficiency may change the set point between PTH and plasma free calcium


Mechanisms by which phosphate retention may lead to hpt
Mechanisms by which Phosphate Retention may lead to HPT

  • Diminishes the renal production of calcitriol

  • Directly increases PTH gene expression

  • Hyperphosphatemia, hypocalcemia, and elevated PTH account for ~17.5% of observed, explainable mortality risk in HD patients with the major cause of death being cardiovascular events


Secondary hpt3
Secondary HPT

  • If phosphate retention is prevented, then secondary hyperparathyroidism does not occur.


If secondary hpt is not corrected
If Secondary HPT is not corrected

  • Renal Osteodystrophy

    • Osteitis fibrosa cystica – predominantly hyperparathyroid bone disease

    • Adynamic bone disease – diminished bone formation and resorption

    • Osteomalacia – defective mineralization in association with low osteoclast and osteoblast activities

    • Mixed uremic osteodystrophy – hyperparathyroid bone disease with a superimposed mineralization defect

  • Metastatic calcification


Renal osteodystrophy
Renal Osteodystrophy

  • Serum intact PTH Predicts severity of HPT, but not necessarily bone disease

  • PTH < 100 pg/mL – adynamic bone disease

  • PTH > 450 pg/mL – hyperparathyroid bone disease and/or mixed osteodystrophy

  • PTH < 200 pg/mL – increased risk of fracture


Renal osteodystrophy1
Renal Osteodystrophy

  • Low serum bone-specific alkaline phosphatase (<= 7 ng/mL) and a low serum PTH suggests a low remodeling disorder

  • Elevated alkaline phosphatase (>= 20 ng/mL) alone or with increased serum PTH (>200 pg/mL) suggests high turnover bone disease.


Low bone turnover
Low Bone Turnover

  • Most patients are asymptomatic

  • Increased risk of fracture due to impaired remodeling

  • Increased risk of vascular calcification due to inability of bone to buffer an acute calcium load


Metabolic acidosis and bone mineral disease
Metabolic Acidosis and Bone Mineral Disease

  • Stimulates physiochemical mineral dissolution buffering excess hydrogen ions

  • Leads to a gradual decline in bone calcium stores

  • Stimulates cell-mediated bone resorption via stimulating osteoclastic activity

  • Alkali therapy can slow progression of uremic bone disease


New classification of bone disease
New Classification of Bone Disease

  • Developed to help clarify the interpretation of bone biopsy results

  • Provide a clinically relevant description of underlying bone pathology

  • Helps define pathophysiology and guide treatment


Vascular calcification
Vascular Calcification

  • Cardiovascular disease remains the leading cause of morbidity and mortality in CKD

  • Disorders of Mineral Metabolism

    • Accelerated atherosclerosis

    • Arterial calcification

    • Increased risk of adverse cardiovascular outcomes and death


Extraosseous calcification
Extraosseous Calcification

  • Calcium phosphate precipitation into joints, arteries, soft tissues, and viscera

  • Calciphylaxis

  • When the fraction of reabsorbed filtered phosphate declines to 15%, PTH cannot increase phosphate excretion but does continue to release calcium phosphate from bone


Phosphorus and calcium in ckd
Phosphorus and Calcium in CKD

  • Hyperphosphatemia brings with it a very high population attributable risk of death

  • Combination of hyperphosphatemia, hypercalcemia, and elevated PTH accounted for 17.5% of observed, explainable mortality in HD patients


Vascular calcification1
Vascular Calcification

  • Late in the disease, fibrofatty plaques protrude into the arterial lumen, leading to a filling defect on angiography

  • Early in the disease, atherosclerosis can be a circumferential lesion without lumen obstruction


Vascular calcification2
Vascular Calcification

  • Dialysis Patients have calcification scores that are two-to five fold greater than age-matched individuals with normal kidney function and angiographically proven CAD

  • Dialysis patients have increased arterial calcification (intimal disease and medial layer thickening) in coronary, renal, and iliac arteries.


Post renal transplant bone disease
Post-Renal Transplant Bone Disease

  • Kidney Transplantation returns patients to CKD and to CKD-MBD.

  • Disorders of mineral metabolism occur post transplant and include:

    • Effects of medications

    • Persistence of underlying disorders

    • Development of hyperphosphaturia with hypophosphatemia


Treatment
TREATMENT

Secondary Hyperparathyroidism Treatment Options



Dietary phosphate restriction
Dietary Phosphate Restriction

  • 800 – 1,000 mg per day

  • Reverses abnormalities of mineral metabolism

    • Increases plasma calcitriol

    • Diminishes PTH levels

    • Improves Ca2+ intestinal absorption


Phosphate binders
Phosphate Binders

  • Limit the absorption of dietary phosphate

  • Calcium Salts

  • Non-calcium containing (sevelamer and lanthanum carbonate)

  • Calcium containing binders should be limited to <1500 mg of elemental calcium per day to keep total calcium intake <2000 mg per day


Phosphate binders1
Phosphate Binders

  • Vitamin D will increase the intestinal absorption of calcium: calcium containing binders should be reduced accordingly

  • Patients with low turnover bone disease will deposit excess calcium in extraskeletal sites because their bones cannot take up the calcium.


Vitamin d
Vitamin D

  • Ergocalciferol

  • Limit dose of active Vitamin D analogues:

  • Paricalcitol

  • Doxercalciferol

  • Calcitriol

  • Dose limited by hypercalcemia and hyperphosphatemia


Vitamin d analogues
VITAMIN D ANALOGUES

  • Reduce dose of active Vitamin D as PTH levels diminish.

  • Adjust dose every 4-8 weeks

  • Discontinue calcitriol during hypercalcemia

  • Contraindicated with PTH levels less than 150 pg/ml


Calcimimetics
Calcimimetics

  • Increase the sensitivity of the CaSR

  • Decrease PTH gene expression

  • Increase Vitamin D receptor expression

  • Can reduce plasma PTH by more than 50%

  • Cinacalcet (Sensipar)

  • Limited by hypocalcemia


Treatment goals in dialysis patients
Treatment Goals in Dialysis Patients

  • Intact PTH between 150-300 pg/mL

  • Serum Phosphate between 3.5-5.5 mg/dL

  • Serum levels of total corrected Calcium between 8.4-9.5 mg/dL


Treatment strategy
Treatment Strategy

  • Reduce Serum Phosphate to normal range

  • Limit Excessive Calcium Loading

  • Use Calcimimetic for elevated PTH with Ca>9.5

  • Avoid active Vitamin D analogues and if used, reduce dose as treatment progresses

  • Prevent progression of parathyroid disease

  • Maintain bone health and prevent fractures


References
References

  • Brenner, Barry M. Brenner & Rector’s The Kidney. 8th Edition. Saunders Elsevier 2008. Pp. 1784-1809.

  • Rose, Burton D. and Theodore W. Post. Chapter 6F: Hormonal Regulation of Calcium and Phosphate Balance. Up To Date 2010. Pp. 1-10.

  • Rose, Burton D. and Theodore W. Post. Chapter 6G: Calcium and Phosphate Metabolism in Renal Failure. Up To Date 2010. Pp. 1-8.

  • Qunibi, Wajeh Y. and William L. Henrich. Pathogenesis of Renal Osteodystrophy. Up To Date 2010. Pp. 1-15.

  • Quarles, Darryl L. Bone Biopsy and the Diagnosis of Renal Osteodystrophy. Up To Date 2010. Pp. 1-17.

  • Quarles, Darryl L. and Robert E. Cronin. Management of Secondary Hyperparathyroidism and Mineral Metabolism Abnormalities in Dialysis Patients. Up To Date 2010. Pp. 1-21.


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