From the Guidelines
The plan of care for this 9-year-old male patient should focus on addressing the abnormal lab values while continuing management of his multiple chronic conditions, prioritizing calcium supplementation and monitoring of renal function, as guided by the 2018 Kidney Disease: Improving Global Outcomes clinical practice guideline update 1.
Key Considerations
- The patient's decreased calcium level of 8.2 should be addressed with calcium supplementation, likely calcium carbonate 500-1000 mg daily with vitamin D to enhance absorption, as vitamin D deficiency is associated with more marked secondary hyperparathyroidism in patients with chronic kidney disease (CKD) 1.
- The patient is already on high-dose vitamin D (50,000 IU twice weekly), which should be continued to help with both calcium absorption and his vitamin D deficiency, with the goal of maintaining serum 25(OH)D levels between 30-50 ng/mL, as recommended by the 2009 KDOQI clinical practice guideline for nutrition in children with CKD 1.
- For the elevated alkaline phosphatase (153), further investigation is warranted to determine if this is related to bone growth (normal in children) or liver dysfunction, and liver function tests should be ordered if not already done, as recommended by the 2018 Kidney Disease: Improving Global Outcomes clinical practice guideline update 1.
- Regarding the elevated vitamin B12 level (1417), no intervention is needed as high B12 levels are generally not harmful, though monitoring is appropriate to ensure it doesn't continue to rise significantly.
Ongoing Management
- The patient should continue all current medications for his chronic conditions, including metoprolol for hypertension, levothyroxine for hypothyroidism, baclofen for spasticity related to his neurological conditions, and Zenpep for maldigestion.
- Regular monitoring of his pressure ulcer is essential, continuing the Silvadene cream application.
- Given his chronic kidney disease, renal function should be closely monitored, especially with medication adjustments, as recommended by the 2018 Kidney Disease: Improving Global Outcomes clinical practice guideline update 1.
- A follow-up appointment in 2-3 months is recommended to reassess lab values and evaluate the effectiveness of interventions.
From the Research
Patient Assessment and Lab Results
The patient presents with a complex medical history, including chronic kidney disease (stage I), hypothyroidism, and paraplegia, among other conditions. The lab results show decreased calcium levels (8.2), elevated alkaline phosphatase (153), and elevated vitamin B12 levels (1417).
Plan of Care
Based on the lab results and medical history, the plan of care for this patient should include:
- Monitoring of calcium and phosphate levels to maintain optimal bone mineralization, as vitamin D plays a crucial role in regulating these levels 2
- Management of elevated alkaline phosphatase levels, which may be associated with cardiovascular disease and mortality in patients with chronic kidney disease 3, 4, 5
- Consideration of the patient's chronic kidney disease and its impact on mineral and bone metabolism, including the potential for vascular calcification and cardiovascular disease 3, 4, 5, 6
- Review of the patient's current medications, including vitamin D supplements, to ensure they are not contributing to the elevated alkaline phosphatase levels or other lab abnormalities
- Potential adjustment of the patient's medication regimen to address the lab abnormalities and prevent further complications
Key Considerations
- The patient's vitamin D deficiency and elevated alkaline phosphatase levels may be related to their chronic kidney disease and should be managed accordingly 2, 3, 4, 5, 6
- The patient's medical history and current medications should be carefully reviewed to identify any potential interactions or contributing factors to the lab abnormalities
- Regular monitoring of the patient's lab results and adjustment of their treatment plan as needed to prevent further complications and improve outcomes 2, 3, 4, 5, 6