Concluded Case

HYPERPARATHYROIDISM with CKD

52 years old female Chief complaints - Generalised weakness will loss of appetite History of present illness - This 52 years old female -a staff nurse posted at GMC - gives history of gradual loss of appetite, general debility ,Generalised aches and pains,and dynoea . No history of respiratory symptoms , no history of fever O/ Examination- Pallor ++, No icterus , Chest and CVS - NAD Neurollgical Examination- Normal INVESTIGATIONS- CBC - Significant finding is Hb - 5.7 gms Iron Studies - Normal S.Vitamin D - 1.34 Intact PTH - Parathyroid hormone - 900 ,8 pg / ml ( Normal range - 15 - 65 pg / ml ) Significantly raised S.Calcium - initially it was less than 5 - but with intensive calcium supplements it raised to 7 mg K.F.T - deranged S. Urea - 82 mg / dl S.creatinine- 4. 1 mg / dl Sodium- 130 meq/ l Potassium- 5.5 meq / l Ultrasonography- CKD changes in kidneys PROVISIONAL DIAGNOSIS- HYPERPARATHYROIDISM WITH CKD OPINIONS WELCOMED - REGARDING MANAGEMENT

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Concluded answer

This is a case of Renal hyperparathyroidism with ESRD , Dyselectrolytemia, Anemia,Ascites, Hypocalcemia and Hypovitaminosis D. Renal hyperparathyroidism is a common complication of CKD charecterised by elevated parathyroid hormone levels secondary to derangement in homeostasis of serum calcium, phosphate and vitamin D. This is more prone to develop cardiovascular problems and bone disease. Chronic kidney failure is the most common cause of secondary hyperparathyroidism. As the parathyroid glands are intact and no adenomas ,we have to consider ckd is cause of hyperparathyroidism. Failing kidneys donot convert enough vitamin D to its active form, and donot adequately excrete phosphate. As a result insoluble calcium phosphate forms in the body and removes calcium in the circulation leading to Hypocalcemia. Coming to the treatment Rule out cause for ESRD like Diabetes Mellitus Hypertension NSAIDS abuse Recurrent urinary tract infections Nephrotoxic drugs,etc 1) ESRD is dead-end complication of chronic kidney Disease and prognosis is not satisfactory unless either Hemodialysis or peritoneal dialysis should be done followed by renal transplantation. 2) Vitamin D 3 supplements 3) Calcium supplements 4) Phosphate binders 5) Restricted diet of phosphate. 6) calcimimetics 7) Erythropoietin injections . 8) If parathyroid glands are enlarged refractorily to medical management, surgery - parathyroidectomy is indicated. 9) As heart is the target organ in case of Chronic kidney disease, Antiplatelets and statins if liver enzymes are normal, can be given . Most Patients with CKD will die from acute myocardial infarction or cardiac arrest or heart failure.

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This is a case of Renal hyperparathyroidism with ESRD , Dyselectrolytemia, Anemia,Ascites, Hypocalcemia and Hypovitaminosis D. Renal hyperparathyroidism is a common complication of CKD charecterised by elevated parathyroid hormone levels secondary to derangement in homeostasis of serum calcium, phosphate and vitamin D. This is more prone to develop cardiovascular problems and bone disease. Chronic kidney failure is the most common cause of secondary hyperparathyroidism. As the parathyroid glands are intact and no adenomas ,we have to consider ckd is cause of hyperparathyroidism. Failing kidneys donot convert enough vitamin D to its active form, and donot adequately excrete phosphate. As a result insoluble calcium phosphate forms in the body and removes calcium in the circulation leading to Hypocalcemia. Coming to the treatment Rule out cause for ESRD like Diabetes Mellitus Hypertension NSAIDS abuse Recurrent urinary tract infections Nephrotoxic drugs,etc 1) ESRD is dead-end complication of chronic kidney Disease and prognosis is not satisfactory unless either Hemodialysis or peritoneal dialysis should be done followed by renal transplantation. 2) Vitamin D 3 supplements 3) Calcium supplements 4) Phosphate binders 5) Restricted diet of phosphate. 6) calcimimetics 7) Erythropoietin injections . 8) If parathyroid glands are enlarged refractorily to medical management, surgery - parathyroidectomy is indicated. 9) As heart is the target organ in case of Chronic kidney disease, Antiplatelets and statins if liver enzymes are normal, can be given . Most Patients with CKD will die from acute myocardial infarction or cardiac arrest or heart failure.

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Its Secondary Hyperparathyroidism due to Vit-D def in CKD.... intensive Vit D supplementation along with Elemental Calcium intake of 1 - 1.5g /day us required.... She must be having Anemia of chronic disease... Peripheral smear is req and give PRBC transfusion

Thank you doctor
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Ensure arteiovenous fistula is in situ..blood transfusion currently during hemodialysis.Rest treatment as adviced by Dr. Sanjaya

First staging of ckd should be done with Cockcroft gault formula using weight and serum creatinine as parameters Then accordingly treatment given Mean while iron supplements given Along with that EPO 4000 IU SC/ week given To control BP anti hypertensive measures taken Tablet alpha keto glutarate given Additionally calcium vitd3 b complex and preprobiotics given

As per symptoms & parameters mentioned.. 1) Corrections of HB level will help for dialysis if needed. 2) Continue with hyperthyroidism and CKD treatment + adding antibiotics to avoid any renal infections.

This is case of hyperthyroidism with CKD. We have to go for USG of thyroid & parathyroid Treatment of hypeprarthyroidism is only surgery of parathyroid. After this level of hyperparathyroidism come down

See for usg thyroid for further management For ckd start sodabicard Mucomix 600mg Tab nephrasave And treat accordingly

Lycopodium phosphorus thyroidinum

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