Challenging Case - Hyperphosphatemia: Management Strategies for Patients on Dialysis

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* 1. Mr. KG is a 52-year-old male on dialysis secondary to diabetes. He has multiple other complications relating to his diabetes including neuropathy, retinopathy, and gastroparesis. He has been on dialysis, thrice weekly, for 2 years. His phosphate levels run between 6.3 and 7.2 mg/dl, his PTH is 500 pg/ml, and his calcium is 9.2 mg/dl. He has had peripheral arterial disease and is status post bilateral BKA. He had a coronary angiogram in anticipation of a kidney transplant but was found to have diffuse calcifications with a recommendation of “medical management only”. He is divorced and lives by himself, with children stopping by on occasion to help him. His current phosphorus binder prescription is calcium acetate 2 tablets three times daily with meals, sevelamer 3 tablets three times daily with meals. He is prescribed cinacalcet 30 mg daily for his hyperparathyroidism. As his care provider, what can you do to improve his serum phosphate?

The most effective treatment in this patient to lower his phosphate level is:

A. Parathyroidectomy

B. Increase his calcium acetate to 2 tabs 3x/day

C. Increase his sevelamer to 4 tabs 3x/day with meals

D. Switch to short home daily dialysis

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* 2. What is your level of confidence that your choice is correct?

High

Medium

Low

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* 3. Additional questions you should ask the patient are:

A. How many times per day does he eat?

B. Who does his grocery shopping and where does he shop?

C. Does he have problem swallowing pills or gastric distress when taking his pills?

D. Does he cook for himself, or eat more processed/prepared foods?

E. All of the above

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* 4. What is your level of confidence that your choice is correct?

High

Medium

Low

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* 5. If you had to guess about this patient’s concern about his phosphate binders what would he say?

A. I take too many pills, sometimes I just don’t feel like taking them.

B. I usually don’t eat true meals, but ‘graze’ throughout the day. My prescription is to take them with meals so some days I don’t take any.

C. I have difficulty swallowing this many pills.

D. I don’t know what pills you are talking about. Are these the round blue pills you are talking about?

E. Tell me again- “what are these pills for?”

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* 6. What is your level of confidence that your choice is correct?

High

Medium

Low