From the Guidelines
The plan of care for this 39-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 vitamin D levels, as supported by the most recent guidelines from the Kidney Disease: Improving Global Outcomes (KDIGO) 2017 clinical practice guideline update 1.
Key Recommendations:
- The decreased calcium level of 8.2 should be addressed with calcium supplementation, such as calcium carbonate 1200-1500 mg daily divided into 2-3 doses, taken with meals to improve absorption, as hypocalcemia can contribute to secondary hyperparathyroidism and renal osteodystrophy 1.
- The elevated alkaline phosphatase (153) may be related to bone turnover from immobility due to paraplegia or possibly liver issues, warranting further investigation with liver function tests and bone-specific alkaline phosphatase to determine the source.
- The elevated vitamin B12 level (1417) suggests excessive supplementation, so any B12-containing supplements should be discontinued.
- The patient should continue his current medications, including the high-dose vitamin D (50,000 IU twice weekly) to address his vitamin D deficiency, which may also help improve calcium levels, as vitamin D deficiency is common in patients with chronic kidney disease (CKD) and can be prevented or corrected by supplementation with vitamin D3 (cholecalciferol) or vitamin D2 (ergocalciferol) 1.
- Regular wound care with Silvadene cream should continue for the stage 4 pressure ulcer.
- Additionally, the patient should be scheduled for a follow-up appointment in 4-6 weeks to reassess lab values and evaluate the effectiveness of interventions.
- Nutritional counseling may benefit this patient given his maldigestion syndrome and the need for proper calcium intake.
- The elevated B12 levels could be related to liver dysfunction or kidney disease, so monitoring of these conditions is important as part of the comprehensive care plan.
Rationale:
The patient's decreased calcium level and elevated alkaline phosphatase require attention to prevent further complications such as secondary hyperparathyroidism and renal osteodystrophy. The continuation of high-dose vitamin D supplementation is supported by guidelines to address vitamin D deficiency, which is prevalent in CKD patients. Monitoring and adjustment of the patient's care plan based on follow-up appointments and lab results are crucial to ensure the effectiveness of interventions and to minimize potential risks associated with hypercalcemia or other electrolyte imbalances.
From the Research
Patient Assessment and Lab Results
The patient presents with a past medical history of multiple conditions, including chronic kidney disease (stage I), and is currently taking various medications. The review of labs shows decreased calcium level, elevated alkaline phosphatase, and elevated vitamin B12 level.
Plan of Care
Based on the patient's lab results and medical history, the plan of care should focus on addressing the following:
- Decreased calcium level: This could be related to the patient's chronic kidney disease and vitamin D deficiency 2, 3. Treatment may involve adjusting the patient's vitamin D supplementation.
- Elevated alkaline phosphatase: This enzyme is involved in bone mineralization and has been linked to inflammation, metabolic syndrome, and vascular calcification in patients with chronic kidney disease 4, 5. The patient's elevated alkaline phosphatase level may be a marker of the inflammatory milieu and could be associated with elevated serum C-reactive protein (CRP) levels 4.
- Elevated vitamin B12 level: This may not be directly related to the patient's current medical conditions, but it is essential to monitor and adjust the patient's supplements as needed.
Treatment Considerations
The patient's treatment plan should consider the following:
- Vitamin D supplementation: Adjusting the patient's vitamin D dosage to address the decreased calcium level and potential vitamin D deficiency 2, 3.
- Alkaline phosphatase management: Considering the patient's elevated alkaline phosphatase level, treatment strategies may involve modulating the expression of alkaline phosphatase directly or indirectly in CKD-mineral and bone disorder (CKD-MBD) 5.
- Medication management: Reviewing the patient's current medications and adjusting as needed to ensure optimal management of their medical conditions.
Key Considerations
The patient's plan of care should take into account the following key considerations:
- Chronic kidney disease management: The patient's treatment plan should focus on maintaining normal calcium and phosphate balance to prevent skeletal and cardiovascular complications 2.
- Inflammation and metabolic syndrome: The patient's elevated alkaline phosphatase level may be a marker of the inflammatory milieu, and treatment strategies should consider this association 4, 5.
- Bone health: The patient's treatment plan should prioritize maintaining optimal bone health, considering the potential risks of bone disorders and mineral disarrays in CKD patients 6.