<prompt> Which among the following is not seen in Chronic Renal Failure?HyperkalemiaHyponatremiaHypercalcemiaHyperphosphatemia  <response>: ANSWER: C HypercalcemiaREF: Harrisons Internal Medicine 17th edition Chapter 274 Table 274-3 Figure 274-1, CMDT 2009 edition Chapter 22 Kidney DiseaseHypocalcemia not hypercalcemia is seen in CRFThe disorders of calcium, phosphorus, and bone are newly referred to as mineral bone disorders of chronic kidney disease see illustration. The most common disorder is osteitis fibrosa cystica-- the bony changes of secondary hyperparathyroidism. This affects 50 of patients nearing ESRD. As GFR decreases below 25 of normal, phosphorus excretion is impaired. Hyperphosphatemia leads to hypocalcemia, stimulating secretion of PTH, which has a phosphaturic effect and normalizes serum phosphorus. This continuous process leads to markedly elevated PTH levelsand high bone turnover with osteoclastic bone resorption and subperiosteal lesions. Metastatic calcifications, such as tumoral calcinosis, can occur. Radiographically, lesions are most prominent in the phalanges and lateral ends of the clavicles.Calciphylaxis is a syndrome of vascular calcification, thrombosis and skin necrosis. It is seen almost exclusively in patients with Stage 5 chronic kidney disease. It results in chronic non-healing wounds and is usually fatal. Calciphylaxis is a rare but serious disease.Calciphylaxis is one type of extraskeletal calcification. Similar extraskeletal calcifications are observed in some patients with hypercalcaemic states, including patients with milk alkali syndrome, sarcoidosis, primary hyperparathyroidism, and hyper vitamin osis DCLINICAL AND LABORATORY MANIFESTATIONS OF CHRONIC KIDNEY DISEASE AND UREMIA:Fluid and electrolyte disturbancesVolume expansion IHyponatremia IHyperkalemia IHyperphosphatemia ICardiovascular and pulmonary disturbancesArterial hypertension I or PCongestive heart failure or pulmonary edema IPericarditis IHypertrophic or dilated cardiomyopathy If Pf or DDermatologic disturbancesPallor IbHyperpigmentation I, P, or DPruritus PEcchymoses INephrogenic fibrosing dermopathy DUremic frost IUremic lung IAccelerated atherosclerosis P or D Hypotension and arrhythmias D Vascular calcification P or DEndocrine-metabolic disturbancesSecondary hyperparathyroidism I or PAdynamic bone DVitamin D-deficient osteomalacia I Carbohydrate resistance IHyperuricemia I or PHypertriglyceridemia I or PIncreased Lpa level PDecreased high-density lipoprotein level PProtein-energy malnutrition I or PImpaired growth and development PInfertility and sexual dysfunction PAmenorrhea IPb-Microglobulin associated amyloidosis P or DNeuromuscular disturbancesFatigue ISleep disorders PHeadache PImpaired mentation I- Lethargy IAsterixis IMuscular irritability Peripheral neuropathy I or P Restless legs syndrome I or P Myoclonus lSeizures I or PComa IMuscle cramps P or DDialysis disequilibrium syndrome D Myopathy P or DGastrointestinal disturbancesAnorexia INausea and vomiting IGastroenteritis IPeptic ulcer I or PGastrointestinal bleeding I, P, or DIdiopathic ascites DPeritonitis DHematologic and immunologic disturbancesAnemia IbLymphocytopenia PBleeding diathesis I or DbIncreased susceptibility to infection I or PLeukopenia DThrombocytopenia DI denotes an abnormality that usually improves with an optimal program of dialysis and related therapy;P denotes an abnormality that tends to persist or even progress, despite an optimal program;D denotes an abnormality that develops only after initiation of dialysis therapy Improves with dialysis and erythropoietin therapy. 