CKD G4 with vitamin D deficiency and secondary hyperparathyroidism — MSRA MCQ

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HardNephrologyCKD G4 with vitamin D deficiency and secondary hyperparathyroidismMSRA

A 69-year-old man with stable CKD G4 due to hypertensive nephrosclerosis attends for review. His eGFR has been 24–26 mL/min/1.73 m² for 8 months. He is clinically euvolaemic and has no bone pain, proximal muscle weakness or pruritus. He takes ramipril and amlodipine; his BP is 132/76 mmHg. Routine CKD monitoring shows adjusted calcium 2.31 mmol/L, phosphate 1.34 mmol/L, bicarbonate 23 mmol/L, alkaline phosphatase 96 IU/L, parathyroid hormone 17.8 pmol/L (reference range 1.6–6.9), and 25-hydroxyvitamin D 19 nmol/L. He has not received vitamin D supplementation previously. What is the most appropriate next pharmacological intervention?

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Correct answer: A — Start colecalciferol replacement

This man has CKD G4, in which calcium, phosphate and parathyroid hormone monitoring is appropriate. His raised parathyroid hormone is consistent with secondary hyperparathyroidism, but the immediately actionable abnormality is severe vitamin D deficiency. NICE recommends colecalciferol or ergocalciferol for vitamin D deficiency in people with CKD. Therefore, colecalciferol replacement is the appropriate first pharmacological step. Alfacalcidol and calcitriol are active vitamin D preparations. In CKD G4–G5, NICE advises considering these only after vitamin D deficiency has been corrected if symptoms of CKD-mineral and bone disorder persist; this patient has not yet received nutritional vitamin D and is asymptomatic. Calcium acetate is used for hyperphosphataemia in CKD G4–G5, but his phosphate is not raised. Oral sodium bicarbonate may be considered when eGFR is below 30 mL/min/1.73 m² and serum bicarbonate is below 20 mmol/L; although his eGFR meets the first criterion, his bicarbonate is 23 mmol/L. The distinction is therefore sequence: correct documented nutritional vitamin D deficiency before considering active vitamin D therapy.

Reference: Chronic kidney disease: assessment and management (NG203), recommendations (Last updated 24 November 2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations Chronic kidney disease: assessment and management (NG203), vitamin D supplements in CKD-mineral and bone disorders (Last updated 24 November 2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations Chronic kidney disease: assessment and management (NG203), oral bicarbonate supplements (Last updated 24 November 2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations