2016.04

1. DR. ASMATULLAH SAPAND
A H M A D S H A H A B D A L I
I N S T U T U T E O F H I G H E R
E D U C AT I O N
D E PA R T M E N T O F
I N T E R N A L M E D I C I N E
K H O S T - A F G H A N I S TA N

2. MANAGEMENT OF COMPLICATIONS
RENAL OSTEODYSTROPHY:
• This is the term used for various forms of bone disease
that develop in chronic renal failure i.e. Osteomalacia,
Osteoporosis, Secondary Hyperparathyroid Bone
Disease And Osteosclerosis.

3. MANAGEMENT OF COMPLICATIONS
1. OSTEOMALACIA:
• Deficiency of 1,25 dihydroxy cholecalciferol(active-
vit.D).
• Low vitamin D results in decreased calcium intestinal
absorption(hypocalcemia).
• Hypocalcemia results in reduction of osteoid
calcification and finally Osteomalacia.

4. MANAGEMENT OF COMPLICATIONS
2. HYPERPARATHYROID BONE DISIEASE:
• Low serum calcium causes PTH secretion from the
parathyroid gland(secondary hyperparathyroidism)
• Resorption of calcium from bone.
• Formation of cysts within the bone(osteitis fibrosa
cystica).

5. MANAGEMENT OF COMPLICATIONS
3. OSTEOPOROSIS: causes from malnutrition in chronic
renal failure.
4. OSTEOSCLEROSIS: cause is unknown and occurs in
sacrum, base of the scull and vertebrae.

6. MANAGEMENT OF COMPLICATIONS
5. CALCIUM, PHOSPHATE AND BONE
ABNORMALITIES:
• GFR below 25% of normal results in low phosphate
excretion(hyperphosphatemia)
• Hyperphosphatemia results in hypocalcemia due to
deposition of calcium phosphate in bone.
• Hypocalcemia results in secondary
hyperparathyroidism and its consequences.

7. MANAGEMENT OF COMPLICATIONS
5. CALCIUM, PHOSPHATE AND BONE ABNORMALITIES:
 Clinical features:
• Bone pain, proximal muscle weakness, fractures, pruritus
and extra-skeletal calcification.
 Treatment:
• Treatment should be started early in the course of
progressive renal failure.

8. MANAGEMENT OF COMPLICATIONS
5. CALCIUM, PHOSPHATE AND BONE
ABNORMALITIES:
 Goal of Treatment:
1. To maintain serum calcium and phosphate.
2. To prevent hyperparathyroidism.
3. To prevent extra-skeletal calcification.
4. To maintain normal bone histology.

9. MANAGEMENT OF COMPLICATIONS
5. CALCIUM, PHOSPHATE AND BONE
ABNORMALITIES:
 Correction of Hyperphosphatemia and secondary
hyperparathyriodism:
1. Dietary restriction of Phosphate
2. Use of Phosphate binding agents

10. MANAGEMENT OF COMPLICATIONS
5. CALCIUM, PHOSPHATE AND BONE
ABNORMALITIES:
1. Dietary restriction of Phosphate:
• Dietary restriction of phosphate is advised when GFR
falls below 50ml/min.
• Goal is to maintain phosphorous level between 4-
5mg/dl.

11. MANAGEMENT OF COMPLICATIONS
5. CALCIUM, PHOSPHATE AND BONE
ABNORMALITIES:
2. Use of Phosphate binding agents:
• Calcium carbonate 500mg-2g orally with meal.
• If phosphorous level cannot be maintained between 4-
5mg/dl or the initial phosphorous level is >7mg/dl then
Aluminium hydroxide 15-30ml is used with meals.

12. MANAGEMENT OF COMPLICATIONS
5. CALCIUM, PHOSPHATE AND BONE ABNORMALITIES:
 Treatment of hypocalcemia:
• If hypocalcemia persists after phosphate has been
controlled, Vit.D3 may be added.
• Alfacalcidol 0.25mcg/day.
• Note: vitamin D increases gut phosphorous absorption and
may therefore exacerbate hyperphosphatemia.

13. MANAGEMENT OF COMPLICATIONS
5. CALCIUM, PHOSPHATE AND BONE
ABNORMALITIES:
 Indications of parathyroidectomy:
• Calciphylaxis.
• Severe hypercalcemia.
• High PTH level.