From the Guidelines
The patient's laboratory results indicate elevated sodium, chloride, calcium, and alkaline phosphatase levels, suggesting possible dehydration and calcium metabolism disorders, and I recommend increasing fluid intake and scheduling a follow-up appointment with a healthcare provider to investigate these abnormalities further, particularly the elevated calcium and alkaline phosphatase, as suggested by the Kidney Disease: Improving Global Outcomes (KDIGO) 2017 clinical practice guideline update 1.
The elevated calcium level could indicate hyperparathyroidism, vitamin D excess, or other calcium metabolism disorders, and the increased alkaline phosphatase might suggest liver or bone issues. The healthcare provider may want to order additional tests such as parathyroid hormone (PTH) levels, vitamin D levels, or imaging studies to determine the cause of these abnormalities.
- The patient's kidney function tests, including glucose, BUN, creatinine, and eGFR, are within normal ranges, which is reassuring.
- The patient's liver enzymes, including AST and ALT, are within normal ranges, which is also reassuring.
- The patient's sodium and chloride levels are elevated, which could be due to dehydration, and increasing fluid intake may help to address this issue.
- The patient's calcium level is elevated, and the KDIGO 2017 clinical practice guideline update recommends avoiding hypercalcemia in patients with CKD stage G3a to G5D 1.
- The patient's alkaline phosphatase level is elevated, which could indicate liver or bone issues, and further investigation is needed to determine the cause of this abnormality.
The most recent and highest quality study, the KDIGO 2017 clinical practice guideline update 1, provides guidance on the diagnosis, evaluation, prevention, and treatment of chronic kidney disease-mineral and bone disorder (CKD-MBD), and recommends monitoring serum levels of calcium, phosphate, PTH, and alkaline phosphatase activity in patients with CKD.
In patients with CKD G3a–G5D, it is reasonable to base the frequency of monitoring serum calcium, phosphate, and PTH on the presence and magnitude of abnormalities, and the rate of progression of CKD, as suggested by the KDIGO 2017 clinical practice guideline update 1.
The patient's healthcare provider should use this guidance to develop a plan to investigate and manage the patient's abnormal laboratory results, and to prevent and treat CKD-MBD.
From the Research
Laboratory Results
- Glucose: 84 mg/dL (normal range: 70-99 mg/dL) [normal]
- BUN: 15 mg/dL (normal range: 8-27 mg/dL) [normal]
- Creatinine: 0.75 mg/dL (normal range: 0.57-1.00 mg/dL) [normal]
- eGFR: 87 mL/min/1.73 (normal range: >59 mL/min/1.73) [normal]
- BUN/creatinine ratio: 20 (normal range: 12-28) [normal]
- Sodium: 146 mmol/L (normal range: 134-144 mmol/L) [above high normal]
- Potassium: 4.6 mmol/L (normal range: 3.5-5.2 mmol/L) [normal]
- Chloride: 107 mmol/L (normal range: 96-106 mmol/L) [above high normal]
- Carbon dioxide, total: 25 mmol/L (normal range: 20-29 mmol/L) [normal]
- Calcium: 10.7 mg/dL (normal range: 8.7-10.3 mg/dL) [above high normal]
- Protein, total: 6.5 g/dL (normal range: 6.0-8.5 g/dL) [normal]
- Albumin: 4.1 g/dL (normal range: 3.9-4.9 g/dL) [normal]
- Globulin, total: 2.4 g/dL [no reference range provided]
- Bilirubin, total: 0.3 mg/dL (normal range: 0.0-1.2 mg/dL) [normal]
- Alkaline phosphatase: 132 IU/L (normal range: 44-121 IU/L) [above high normal]
- AST (SGOT): 13 IU/L (normal range: 0-40 IU/L) [normal]
- ALT (SGPT): 13 IU/L (normal range: 0-32 IU/L) [normal]
Relevant Studies
- A study on metabolic acidosis in advanced renal failure found that patients with diabetes had a less severe metabolic acidosis compared to those without diabetes 2.
- Diuretics can affect calcium homeostasis, with loop diuretics increasing calcium excretion and thiazide diuretics decreasing calcium excretion 3.
- Maintaining fluid and electrolyte balance is crucial in patient care, and monitoring key electrolytes and their imbalances is essential 4.
- Loop diuretics are commonly used in clinical practice, and their pharmacokinetics, dosing, and side effects should be considered 5.
- The combination of calcium channel blockers and diuretics has been shown to be effective in reducing the risk of myocardial infarction and stroke in hypertensive patients 6.