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1. Chronic Kidney Disease
Mineral & Bone Disorder
Mohammed Abdel Gawad
Nephrology Specialist
Kidney & Urology Center (KUC)
Alexandria – EGY
Think Outside
The Box
Case Scenarios Snapshots
5th Annual Conference – Tanta Univ. Nephrology Unit – 31 March 2015

2. For more lectures visit
www.NephroTubeCNE.com
To download the lecture contact me on
drgawad@gmail.com

3. MBD
+
MVD
+
MSD
CKD - MBD

4. ESRD + Hypercalcemia
+ Inappropriately low PTH for the renal
failure
Case 1

5. Case 1
A 31 year old man with hemodialysis
dependent ESRD secondary to
neglected untreated GN
Monthly routine check up:
 Ca: 11.5mg/dl
 Phosphorus: 5.9 mg/dl
 PTH: 180 pg/ml

6. Case 1
A 31 year old man with hemodialysis
dependent ESRD secondary to
neglected untreated GN
Monthly routine check up:
 Ca: 11.5mg/dl
 Phosphorus: 5.9 mg/dl
 PTH: 180 pg/ml
Medications stopped:
Calcium Carbonate
For follow up of Ix
after 2 weeks
Admitted to the hospital
+ Investigations
Within 12 days:
Sever abdominal pain + Nausea &
vomiting + lethargy & weakness
Hospital Admission Ix:
 Ca: 13 mg/dl
 Phosphorus: 6 mg/dl
 PTH: 170 pg/ml

7. Case 1
A 31 year old man with hemodialysis
dependent ESRD secondary to
neglected untreated GN
Hospital Admission Ix:
 Ca: 13 mg/dl
 Phosphorus: 6 mg/dl
 PTH: 170 pg/ml

8. Case 1
A 31 year old man with hemodialysis
dependent ESRD secondary to
neglected untreated GN
Hospital Admission Ix:
 Ca: 13 mg/dl
 Phosphorus: 6 mg/dl
 PTH: 170 pg/ml
 Thyroid function test: normal
 Serum protein electrophoresis: normal

9. Case 1
A 31 year old man with hemodialysis
dependent ESRD secondary to
neglected untreated GN
Hospital Admission Ix:
 Ca: 13 mg/dl
 Phosphorus: 6 mg/dl
 PTH: 170 pg/ml
 Thyroid function test: normal
 Serum protein electrophoresis: normal
 CT Abdomen & Pelvis: Punctate lesions
(multiple small areas of decreased
signal intensity) in the spleen and liver
 CXR: reticulonodular opacities with
extensive hilar nodal enlargement
Archived, identical image
(not the patient own image)

10. Case 1
A 31 year old man with hemodialysis
dependent ESRD secondary to
neglected untreated GN
Hospital Admission Ix:
 Ca: 13 mg/dl
 Phosphorus: 6 mg/dl
 PTH: 170 pg/ml
 Thyroid function test: normal
 Serum protein electrophoresis: normal
 CT Abdomen & Pelvis: Punctate lesions
(multiple small areas of decreased
signal intensity) in the spleen and liver
 CXR: reticulonodular opacities with
extensive hilar nodal enlargement
Archived, identical image
(not the patient own image)

11. Case 1
A 31 year old man with hemodialysis
dependent ESRD secondary to
neglected untreated GN
Hospital Admission Ix:
 Ca: 13 mg/dl
 Phosphorus: 6 mg/dl
 PTH: 170 pg/ml
 Thyroid function test: normal
 Serum protein electrophoresis: normal
 Work up for T.B.: negative
 Vit D level: Normal !!!
Hypercalcemia +
Hyperphosphatemia +
Inappropriately low PTH for the
renal failure + absence of drug
intake + normal vit D level +
spleenomegaly + CXR changes
Sarcoidosis
Oral prednisolone → his serum
calcium level decreased to normal
limits.
 CT Abdomen & Pelvis: Punctate lesions
(multiple small areas of decreased
signal intensity) in the spleen and liver
 CXR: reticulonodular opacities with
extensive hilar nodal enlargement

12. Case 1
A 31 year old man with hemodialysis
dependent ESRD secondary to
neglected untreated GN
In the presence of
ESRD +
↑ Ca + ↑ Phosphorus
+ Inappropriately ↓ PTH for the renal
failure,
a non- PTH mediated cause for the
hypercalcemia must be thought of.

13. Tertiary vs Primary
Hyperparathyroidism
in CKD Patient
Case 2

14. Case 2
A 50 year old male. History of HTN,
IHD and ESRD. On maintenance
hemodialysis since 2 years.
Lab Jul Aug Sept Oct Nov Dec Jan
Ca
(mg/dl)
9.8 10.5 10 10.1 9.7 10.9 17.28
Phosphorus
(mg/dl)
5.3 4.6 4.8 4.2 4 4.5 4.8
PTH
(pg/ml)
350 ------- ------- 320 ------- ------- 1142.8

15. Case 2
A 50 year old male. History of HTN,
IHD and ESRD. On maintenance
hemodialysis since 2 years.
Lab Jul Aug Sept Oct Nov Dec Jan
Ca
(mg/dl)
9.8 10.5 10 10.1 9.7 10.9 17.28
Phosphorus
(mg/dl)
5.3 4.6 4.8 4.2 4 4.5 4.8
PTH
(pg/ml)
350 ------- ------- 320 ------- ------- 1142.8
Ca-Phosphrous-PTH Lab Results Trend
(on & off calcium supplements, phosphate binders &
alphacalcidol according to trends)
?? Primary Hyperparathyroidism

16. Case 2
A 50 year old male. History of HTN,
IHD and ESRD. On maintenance
hemodialysis since 2 years.
Lab Jul Aug Sept Oct Nov Dec Jan
Ca
(mg/dl)
9.8 10.5 10 10.1 9.7 10.9 17.28
Phosphorus
(mg/dl)
5.3 4.6 4.8 4.2 4 4.5 4.8
PTH
(pg/ml)
350 ------- ------- 320 ------- ------- 1142.8
Neck USS
A large, elongated, hypoechoic, hypervascular mass with
internal cystic change was found behind the entire left lobe
of the thyroid suggesting either
a massive single parathyroid adenoma or separate
adenomas immediately adjacent to each other.
Archived, identical image
(not the patient own image)

17. Case 2
A 50 year old male. History of HTN,
IHD and ESRD. On maintenance
hemodialysis since 2 years.
Lab Jul Aug Sept Oct Nov Dec Jan
Ca
(mg/dl)
9.8 10.5 10 10.1 9.7 9.9 17.28
Phosphorus
(mg/dl)
5.3 4.6 4.8 4.2 4 4.5 4.8
PTH
(pg/ml)
350 ------- ------- 320 ------- ------- 1142.8
A large, elongated, hypoechoic, hypervascular mass with
internal cystic change was found behind the entire left lobe
of the thyroid. It measured 1.7 × 1 cm in the transverse
plane and 5 cm in the longitudinal plane, suggesting either
a massive single parathyroid adenoma or separate
adenomas immediately adjacent to each other.
Microscopic examination revealed a densely cellular
proliferation of neoplastic chief, uniformly round,
regular nuclei with smooth nuclear membranes, small
variably prominent nucleoli and abundant granular
cytoplasm. Features suspicious for carcinoma
Neck USS
Surgical excision
Constipation,
N&V,
Generalized
weakness
Symptomatic
treatment,
Cinacalcet,
Frequent
dialysis

18. Case 2
A 50 year old male. History of HTN,
IHD and ESRD. On maintenance
hemodialysis since 2 years.
When to suspect Primary Hyperparathyroidism in CKD
patients?
- ↑ Ca + ↑ PTH (although of control of Ca & PTH within
targets in previous trends).
- ↑ Ca + ↑ PTH (which is not correlated with CKD Stage).
Recommendation: Therapeutic decisions must base on
trends rather than on a single laboratory value.

19. Bone pain may not be due to
CKD-MBD !!
Case 3

20. Case 3
70 years old male. ESRD due to
APKD. He is on maintenance
haemodialysis since 10 years.
His main major complaint
was bone pain allover her
body.

21. Case 3
70 years old male. ESRD due to
APKD. He is on maintenance
haemodialysis since 10 years.
His main major complaint
was bone pain allover her
body.
PTH-Ca-Phosphorus are well
controlled according to Lab trends
and within recommended guidelines
targets
Persistent sever bone pain
especially right shoulder
Multiple
Online HDF
sessions
-2 microglobulin
associated amyloidosis??
Serum -2 microglobulin:
460 mg/L
Improvement of serum -2
microglobulin
But
No improvement of bone
pain (especially right
shoulder)

22. Case 3
70 years old male. ESRD due to
APKD. He is on maintenance
haemodialysis since 10 years.
My grandfather
diagnosed as prostatic
carcinoma
Our patient
How was he diagnosed?
I have a history of brain
and intestinal tumors.
I want to check!!
He did a Lab test that is
called serum PSA
His HD mate

23. Case 3
70 years old male. ESRD due to
APKD. He is on maintenance
haemodialysis since 10 years.
Doctor !!
I want to check my
serum PSA level

24. Case 3
70 years old male. ESRD due to
APKD. He is on maintenance
haemodialysis since 10 years.
Doctor !!
I want to check my
serum PSA level
PSA level: 17 ng/ml
Biopsy: Prostatic Adenocarcionma
Urology & Oncology consultation
CT Staging
Hormonal
Therapy
Gadolinium MRI Scan
Bone metastasis Rt shoulder
and other scattered areas
Pelvic LN
Radiotherapy
Bone pain improved PSA: normal range

25. Case 3
70 years old male. ESRD due to
APKD. He is on maintenance
haemodialysis since 10 years.
When to suspect that bone pain is due to
metastasis or any other cause rather than the
natural history & course of CKD?
When to suspect hidden malignancy
(especially prostatic) in HD patients?
Suggestion: Annual PSA for any
HD patient of age 60 year or older

26. May non compliance of the patient be
an indication for Parathyroidectomy?
Case 4

27. Case 4
40 years old female. ESRD and HTN
following delivery since 8 years. She
is on maintenance haemodialysis.
Her main major complaint was
bone pain allover her body.

28. Case 4
40 years old female. ESRD and HTN
following delivery since 8 years. She
is on maintenance haemodialysis.
Her main major complaint was
bone pain allover her body.
• Phosphorus: 5.3 mg/dl
• Calcium: 9.3 mg/dl
• PTH: 670 pg/ml
• Alphacalcidol
• Ca acetate within meals
• Follow up after 2 weeks
Patient lost follow up
for 6 months
• Ca: 11.2 mg/dl
• Phosphrous: 8 mg/dl
• PTH: 888 pg/ml
• Cinacalcet
• Sevelamer
• Follow up after 2 weeks
After 6 months she
presented to again with
the same bone pain.
Patient lost follow up
for 5 months

29. Case 4
• After 5 months:
 PTH: 1250 pg/ml
 Ca: 7.7 mg/dl
 PO4: 10.5 mg/dl
 Sever neck pain and parathesia
X ray
Cervical spine
40 years old female. ESRD and HTN
following delivery in 2010. She is on
maintenance haemodialysis.

30. Case 4
40 years old female. ESRD and HTN
following delivery in 2010. She is on
maintenance haemodialysis.
• After 5 months:
 PTH: 1250 pg/ml
 Ca: 7.7 mg/dl
 PO4: 10.5 mg/dl
 Sever neck pain and parathesia
X ray
Cervical spine

31. Case 4
MRI
Cervical spine
40 years old female. ESRD and HTN
following delivery in 2010. She is on
maintenance haemodialysis.
• After 5 months:
 PTH: 1250 pg/ml
 Ca: 7.7 mg/dl
 PO4: 10.5 mg/dl
 Sever neck pain and parathesia

32. Case 4
We asked for Neuro-Surgery
consultation
Lost follow up again for very
very very very………. long time
She came back after long time
X ray – Cervical spine – after
surgery
• Sever generalized bone pain
• Presented with hypotension
(the patient was always
hypertensive) which is more
evident on dialysis machine.
40 years old female. ESRD and HTN
following delivery in 2010. She is on
maintenance haemodialysis.
• After 5 months:
 PTH: 1250 pg/ml
 Ca: 7.7 mg/dl
 PO4: 10.5 mg/dl
 Sever neck pain and parathesia

33. Case 4
We asked for Neuro-Surgery
consultation
Lost follow up again for very
very very very………. long time
She came back after long time
X ray – Cervical spine – after
surgery
• Sever generalized bone pain
• Presented with hypotension
(the patient was always
hypertensive) which is more
evident on dialysis machine.
40 years old female. ESRD and HTN
following delivery in 2010. She is on
maintenance haemodialysis.
• After 5 months:
 PTH: 1250 pg/ml
 Ca: 7.7 mg/dl
 PO4: 10.5 mg/dl
 Sever neck pain and parathesia
May non compliance of the patient be
an indication for Parathyroidectomy?

34. Home Message
Think Outside The Box
CKD patients may develop any
intercurrent primary or secondary
disorders rather than the excepted
course and complications of CKD

35. For more lectures visit
www.NephroTubeCNE.com
To download the lecture contact me on
drgawad@gmail.com

36. Gawad
Thank You