What is your approach to an elevated alkaline phosphatase level in an ESKD patient with normal PTH, phosphorus, and calcium levels?

I find that the PTH and alkaline phosphatase levels correlate pretty well in ESRD. Normal PTH for ESRD patients is 150-600 or higher, which is significantly higher than in the general population. I would be hesitant to attribute an elevated alkaline phosphatase level to anything other than bone dise...

High serum alkaline phosphatase (AlkPhos) is a stronger and more consistent predictor of adverse outcomes, including high mortality, in patients receiving dialysis than parathyroid hormone (PTH) or serum mineral parameters (Ca, Phos). Yet, AlkPhos is rarely emphasized during routine monthly laborato...

Alk Phos (AP) is the LAST thing to go up in renal secondary hyperPTH, and it tells me there is more than you are dealing with, a high PTH and a high Po4, and this is indicated by the AP being the best predictor of hungry bone syndrome following PTHectomy.

So if I see a high AP without an abnormally ...

I would approach this as any other patient with elevated AP. Is it new? LFTs normal or abnormal? What does the liver and skeleton look like? Etc.