CKD MBD

A 55-year-old male with CKD G4 (eGFR 25 mL/min/1.73 m²) has a history of two fragility fractures in the past year. His serum phosphate is elevated, and PTH is progressively rising.
Question: Which of the following is the most appropriate next step in managing his bone disease?

• Perform a bone biopsy to assess renal osteodystrophy.

• B. Initiate bisphosphonate therapy without further testing.

• Perform dual-energy X-ray absorptiometry (DXA) to assess fracture risk.

• Start calcitriol therapy to lower PTH levels.

A 60-year-old female with CKD G5D (on hemodialysis) has a serum phosphate level of 6.5 mg/dL. She is currently on calcium-based phosphate binders.

Question: What is the most appropriate next step in managing her hyperphosphatemia?

• Increase the dose of calcium-based phosphate binders.

• Switch to a non-calcium-based phosphate binder.

• Initiate calcitriol therapy to lower PTH levels.

• Perform a bone biopsy to assess bone turnover.

A 45-year-old male with CKD G4 (eGFR 22 mL/min/1.73 m²) has a PTH level of 250 pg/mL (upper limit of normal for the assay is 65 pg/mL). His serum calcium and phosphate levels are within normal limits.

Question: What is the most appropriate management for his elevated PTH?

• Start calcitriol therapy immediately.

• Monitor PTH trends and evaluate for modifiable factors like vitamin D deficiency.

• Initiate cinacalcet therapy to lower PTH.

• Perform a parathyroidectomy.

A 50-year-old female with CKD G5D (on hemodialysis) has persistent hypercalcemia (serum calcium 10.8 mg/dL) and elevated PTH levels.

Question: What is the most appropriate dialysate calcium concentration for her?

• 1.00 mmol/L (2.0mEq/L).

• 1.25 mmol/L (2.5 mEq/L).

• 1.75 mmol/L (3.5 mEq/L).

• 2.00 mmol/L (4.0 mEq/L).

A 65-year-old male with CKD G5D (on hemodialysis) has low bone mineral density (BMD) and a history of fragility fractures. His PTH levels are persistently low.

Question: What is the most appropriate next step in managing his bone disease?

• Initiate bisphosphonate therapy without a bone biopsy.

• Perform a bone biopsy to assess bone turnover.

• Start calcitriol therapy to increase PTH levels.

• Increase dietary phosphate intake.

A 70-year-old male with CKD G4 (eGFR 28 mL/min/1.73 m²) has a serum phosphate level of 5.2 mg/dL. He consumes a diet high in processed foods.

Question: What is the most appropriate dietary recommendation for him?

• Increase intake of animal-based proteins.

• Limit dietary phosphate intake and focus on fresh, homemade foods.

• Start calcium-based phosphate binders.

• Increase intake of plant-based proteins.

A 58-year-old female with CKD G5D (on hemodialysis) has a serum calcium 8.0 mg/dL while on cinacalcet therapy.

Question: What is the most appropriate management for her hypocalcemia?

• Increase dialysate calcium concentration to 1.75 mmol/L.

• Administer intravenous calcium gluconate.

• Monitor if asymptomatic.

• Discontinue cinacalcet therapy.

A 52-year-old male with CKD G4 (eGFR 24 mL/min/1.73 m²) has a PTH level of 300 pg/mL. He has not been on Vitamin D Therapy.

Question: What is the most appropriate management for his vitamin D deficiency?

• Start calcitriol therapy.

• Correct vitamin D deficiency as for the general population.

• Initiate paricalcitol therapy.

• Perform a bone biopsy to assess bone turnover.

A 60-year-old male with CKD G5D (on hemodialysis) has a PTH level of 800 pg/mL. His serum calcium is 9.5 mg/dL, and phosphate is 5.8 mg/dL.

Question: What is the most appropriate PTH-lowering therapy for him?

• Start Calcitriol

• Start Cinacalcet

• Start cinacalcet and calcitriol.

• Parathyroidectomy.

A 45-year-old female, 6 months post-kidney transplant, has an eGFR of 40 mL/min/1.73 m² and a history of osteoporosis.
Question: What is the most appropriate management for her bone disease?

• Perform a bone biopsy to assess bone turnover.

• Initiate bisphosphonate therapy without further testing.

• Measure BMD to assess fracture risk.

• Start calcitriol therapy to prevent bone loss.