S LESTARI 1,I KUSWADI 1, R PRASANTO 1
1Division of Renal dan Hypertension, Department of Internal Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
Background: Hyperparathyroidism and hyperphosphatemia are common in patients with chronic kidney disease (CKD). There are a small number of CKD and hypoparathyroidism patients. The effect of hypoparathyroidism on serum phosphate (Pi) in these patients has rarely been reported.
Case report: A 34-years-old man with CKD has been undergoing hemodialysis for 15 years. The dialysis session was 5-hour, twice a week. Dialysate Ca and Mg were 1.9 and 1 mmol/L, respectively. The BMI was 19.07 kg/m2, blood pressure 150/90 mmHg, conjunctiva anemic, lung and heart within normal limits, no ascites nor limb edema. The laboratory results were hemoglobin 9.5 g/dL, calcium 2.79 mmol/dL, Pi 2.6 mg/dL, magnesium 3.67 mg/dL, random glucose 120 mg/dL, albumin 4.08 g/dL, parathyroid hormone (PTH) 3.04 pg/mL. He got calcium carbonate as a phosphate-binder and was stopped since hypophosphatemia was detected. He didn’t receive vitamin D/analogue. The recent evaluation results were Pi 1.1 mg/dL, calcium 2.33 mmol/dL, IL6 3.25 pg/mL, CRP 1.3 mg/L, Vit D 25-OH levels 19.5 ng/mL. Ultrasound of the parathyroid glands revealed the left parathyroid atrophy.
Many reports revealed, the causes of hypoparathyroidism are parathyroidectomy, diabetes mellitus, hypercalcemia, administration of vitamin D/analogues, phosphate binders, calcium-sensing receptor antagonists, and malnutrition-inflammation complex syndrome. Factors that may influence hypoparathyroidism in this patient are hypermagnesemia and atrophy of the left parathyroid glands. Immunological tracing hasn’t been conducted. Treatment of this patient may be taken by lowering dialysate magnesium concentration. A high phosphate diet is recommended.
Conclusion: A CKD patient on hemodialysis has low levels of Pi and PTH. Treatment is conducted by lowering dialysate magnesium concentration and high phosphate diet.
Sri Lestari is an internist at the Tjitrowardojo Hospital, Purworejo, Central Java, Indonesia. She completed her medical doctor degree at Universitas Gadjah Mada in 2000. She became an internist in 2014 at Universitas Gadjah Mada. Currently, she is a fellow of nephrology at Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada.