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Calcium Binder Switch Elevated CaPO4 Product — ESENeph MCQ

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ModerateHaemodialysisCalcium Binder Switch Elevated CaPO4 ProductESENeph

A 62-year-old man with CKD G5D on haemodialysis develops pruritus and a raised, annular, erythematous rash on his trunk. Skin biopsy shows dermal calcium deposits. His calcium-phosphate product is 5.8 mmol2/L2. He is on calcium acetate and alfacalcidol. Aside from treating calciphylaxis, what is the FIRST medication change?

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Correct answer: C — Stop calcium acetate and switch to sevelamer or lanthanum

When calcium-phosphate product is elevated and dermal calcification is present, calcium-containing phosphate binders must be stopped immediately. They contribute directly to the calcium load and promote vascular and soft tissue calcification. Switching to non-calcium binders (sevelamer hydrochloride/carbonate or lanthanum carbonate) removes the exogenous calcium burden. Alfacalcidol should also be reduced or stopped as it increases calcium absorption. This medication change addresses the root cause rather than just treating symptoms. Intensified dialysis (longer/more frequent sessions) is also beneficial for phosphate clearance but the binder switch is the immediate correctable step.

Reference: KDIGO 2024 – CKD-MBD Guideline; UKKA 2015 – CKD-MBD