Harrison's PodClass: Internal Medicine Cases and Board Prep Ep 187: A 73-Year-Old with Complications from Renal Dysfunction
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Mar 19, 2026 A deep dive into complications from worsening renal dysfunction. They cover when to start goals-of-care discussions as kidney function declines. Conversation highlights vitamin D activation failure, hypocalcemia signs, and FGF23’s role in phosphate handling. Management topics include phosphate restriction, activated vitamin D, binders, and monitoring PTH and magnesium.
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CKD Progression Triggers Care Planning
- Chronic kidney disease often progresses despite optimal therapy and aging, with GFR decline moving patients from stage 3 to stage 4 as in this 73-year-old case.
- When GFR falls below 30 mL/min start goals-of-care and dialysis discussions; renal replacement is typically considered when GFR <15 mL/min.
Why CKD Causes Hypocalcemia
- Reduced renal 1-alpha hydroxylation lowers active 1,25-(OH)2 vitamin D, causing hypocalcemia and secondary hyperparathyroidism in CKD.
- These patients characteristically develop hyperphosphatemia rather than hypophosphatemia as kidney function worsens.
Recognize Symptoms Of Chronic Hypocalcemia
- Monitor for chronic hypocalcemia symptoms including paresthesias, muscle spasms, laryngeal spasm, seizures, and prolonged QT on ECG.
- Watch for neuropsychiatric signs like irritability, depression, and possible papilledema from increased intracranial pressure.
