Hi
A 55 y/o female with chronic liver diseases from hepatitis c on HD since 5 years. She is HCV positive. In the last year she has been on only twice weekly for HD due to non compliance. Her investigations repeatedly showed very low serum Ca around 4.5-5 mg/dl despite high dose calcium carbonate 500 mg po qid supplementation, Her Phosp is 6 , PTH 650, K 5.7, Na 135, BUN 90, Cr 7 & albumin 3.8, bicarb 18 . Also, in the last few months her LFT became impaired where previously it was normal . Last LFT showed TB 4.0, ALT 506, ASL 395, Alp 211. HB 10, WBC 5000 & platelet 70,000, she is on venofer twice weekly injection & epogen 4000 unit twice weekly injection. US shows cirrhosis changes and liver cysts.
Any one face this scenario?
Your input are much appreciated.
I suspect she is fairly acidotic (as azotemic and underdialyzed as she appears to be) and thus her ionized Ca is higher than one might predict based on the total Ca alone. Regardless, Have you checked her Vit D levels or just empirically started her on 1-25 Vit D? This may be the problem?
She is probably very acidotic hence tolerating hypocalcemia. I think you can attempt to use calcitriol and titrate dose upwards to reach acceptable Ca, Ph and PTH levels. Few years ago, when there was a surge in enthusiasm to supplement nutritional Vitamin D in CKD. In our experience when we started checking 25OH D levels in our dialysis units, some patients had undetectable levels, yet none of those who were taking calcitriol had hypocalcemia despite having undetectable 25 OH D levels.I would suggest to check also alkaline phosphatases (preferably bone isoenzyme) and serum calcitonin levels.in fact, the biochemical data suggest a form of resistance to the PTH-mediated bone resorption effects