<prompt> A 60 year old male was diagnosed with end stage kidney disease 5 years ago has been managed with hemodialysis since then. He is also hypeensive diabetic. He is not compliant with his medications hemodialysis schedule now presented with bone pain dyspnea. CXR shows hazy bilateral infiltrates. Chest CT shows ground-glass infiltrates bilaterally. Lab studies show elevated levels of calcium phosphate, PTH levels of 130 pgml. What would be the best management for this patient?Calcitriol 0.5 mg IV with hemodialysis with sevelamer three times dailyCalcitriol 0.5 mg orally daily with sevelamer 1600 mg three times dailyMore aggressive hemodialysis to achieve optimal fluid and electrolyte balanceParathyroidectomy  <response>: Given scenario suggests the diagnosis of teiary hyperparathyroidism- commonly seen in patients with chronic kidney disease who are poorly compliant with therapy. Features- bone pain, ectopic calcification pruritus. Hypoxemia and ground-glass infiltrates on chest CT represent ectopic calcification of the lungs. A technetium-99 bone scan will show increased uptake in the lungs. Lab- Elevated calcium, phosphates PTH levels Rx- Parathyroidectomy is done in this patient because of severe clinical manifestations. 