(follow-up) Dropping Labs- Old Timer Seeking Informed Opinions/ Advice

Other than immediately post op surgical for various non-WLS surgeries, my labs have been OK. It's been about 9 months between lab work, and i've bombed.  I went to my Primary because I felt light headed, woozy, and overnight had gone from mod dependant ankle edema in the evening, to knee to toe, skin bursting, drippy edema. 
   Hx-   I've been anemic my whole life...lg blood cells, lower Hgb, Hct... this isn;t too different.
BUT  my calcium has dropped, they didn't order a PTH and I didn't notice, my protein is slightly below normal for the first time, and my serum chloride and creatine is slightly elevated.  My albumin is slightly below, again, something new....  my iron sats are high, but my binding capacity is low.  My B's are off the chart.

I immediately cut back on the B supplementation,  started 2 protein shakes a day (although I was getting in over 100 gms in food), am trying to figure out if I can add in any more calcium supplements (I do 2000mg/day in divided doses).  I can add some more foods with calcium, although I eat a LOT of cheese, yogurt, etc.     I am on Lasix 20mg once a day already.
    I have developed more frequent acid reflux while sleeping in the past few months.  Chalked it up to taking a bedtime dose of zinc  (med list attached below)
   Here are the numbers that are off:  (and the Labs reference ranges)
      Copper   67  (70-155)
     B12         1751  (211-946)
      Ferritin  300   (73-150)
     Iron Bind Capac  161  (250-450)
     UIBC      57  (150-375)
     Serum Iron  104  (35-155)
     Iron Sat     65  (15-55)
         CBC    RBC  2.84  (3.8-5.1)
                      Hgb  10.9  (11.5-15)
                      HCT  30.6  (34-44)
                      MCV  108  (80-98)
                      MCH  38.4  (27-34)
Comp Met Panel
                      serum creat  1.03  ().57-1.0)
                       serum chloride  110  (97-108)
                      serum calcium  8.3  (8.7-10.2)
                       serum protein  5.7  (6.0-8.5)
                      serum albumin  2.9  (3.5-5.5)
                      A/G ratio         1.0   (1.1-2.5)

Vitamin Schedule     Mary C Early AM                            B12                                       1000mcg (QOD)                                                 Vitamin D                        50,000 i.u.   D3                                                 Calcium                              (3) 750mg to equal 2000mg divided doses                                                 Probiotic                           (Whole Foods Double Strength) After Breakfast              Multivitamin                                                 Vitamin K                          1000iu K1                                                 Lasix                                     20mg   Prescription diuretic                                                 Zinc                                       50 mg Lunch                                  Calcium (3)                       750mg                                                 Vitamin D 50,000i.u. (D3)                                                 Biotin Afternoon                             Vitamin C                          1000mg w/ Rose Hips                                                 Iron                                       65                                                 Probiotic                           (Whole Foods Double Strength)                                                 Zyzol                                     Prescription Allergy med Dinner                                Calcium (2)                      500mg                                                 Vitamin D                         50,000 iu D3 Bedtime                            Zinc                                       50mg                                                 Probiotic                           (Whole Foods Double Strength) Calcium- Kirkland 2=500mg Calcium, 800iu D3, 10mg B6, 80mg Magnesium, 10mg Zinc, 1mg Copper, 1mg Manganese, 1mg Boron
Vit K, D from Vitalady dry form If you read this far, I THANK YOU for your perserverance.....  my primary is not well versed, despite my best efforts, in DS health.  I can't find a local nut that is DS aware either....    I'm upping the protein, lowering the B's, and thinking about doing a month of Prilosec, just in case there's a small drippy leak starting from years of vites on the stomach wall at bedtime.... my colonoscopy 8 months ago had no abnormailities....  What are your best guesses?  Don't worry, I KNOW all advice here is just that...  our collective experiences...   I will continue to get this checked out, but need to know which way to steer the boat...   Thanks....   Mary

Honey, with your symptoms, you need to have a FULL Lab workup.  The only B that you have listed is B12 and that number is fine, but you need to check your other B's as well.  Just an FYI, the Kirkland Calcium Citrate has added B vites in them.  I had to switch away from the Kirkland Cal Citrate because my B6 went through the roof, and that was the only supplement I was taking that contained B6.  Here is the list that I run per vitalady:

Not to be construed as medical advice. This list includes labs we have performed as gastric bypass patients.
 
1st Group (Every 3 to 6 months for life, as we are able)
 *8005               Comprehensive Metabolic profile: (sodium, potassium, chloride, glucose, BUN, creatinine, calcium, total protein, albumin, total bilirubin, alkaline phosphatase, aspartate aminotransferase) 10231)
* 7600                 Lipid profile: (cholesterol, HDL, LDL, triglycerides, chol/HDL ratio)
* 84100               Phosphorous – Inorganic: (718)
* 84550               Uric Acid: (905)
* 85025               Hemogram with platelets: (1759)
* 83550               Ferritin: (457)
* 84446               Vitamin A: (921)
* 84052               Vitamin B-1: (Thiamin) (4052)
* 7065                  Vitamin B-12 & Folate: (82607; 82746)
* 83937               Osteocalcin:
* 85610               PT:
* 86141               C Reactive Protein
* 84134               Pre-albumin:
* 10256               Hep panel: includes ALT (SPGT) & GGT)
* 83735               Magnesium:
* 7444                 Thyroid panel: (T3U, T4, FTI, TSH) (84437; 84443; 84479; 84480)
* 7573                 Iron: TIBC, % sat
* 84630               Zinc: (945)
* 8230                  Vitamin D: (25-hydroxy) (680)
* 84207               Vitamin B-6: (Pyridoxine)
* 83970               Serum intact: PTH
* 84597               Vitamin K:
* 85730               PTT:
 
2ND GROUP (Annually, as long as the results were comfortably within normal limits for more than 2 years in a row)
 
* 593                    LDH:
* 83921               MMA:
* 84255               Selenium:
* 82525               Copper:
* 31789               Homocysteine, Cardio:
* 367                    Cortisol:
* 84590               Vitamin E:
 
For diabetics:
*496                     HEMOGLOBIN A1C
 
POSSIBLE DIAGNOSIS CODES
269.2                             Hypovitaminosis
269.8                             Vitamin D deficiency
275.40                           Calcium deficiency
266.2                             Cyanocobalamin deficiency (B12)
281.1                             other B12 deficiency anemia
281.0                             Pernicious anemia
280.9                             Iron-deficiency anemia
281.2                             Folate deficiency anemia
285.9                            Anemia, unspecified
269.3                             Zinc deficiency
244.9                             Hypothryoidism
250.0                             Diabetes
401.9                             Hypertension
276.9                             Electrolyte and fluid disorders
272.0                             Hypercholesterolemia
*579.3                            Surgical malabsorption*
*579.8                            Intestinal malabsorption *
* Bands or sleeves should not use these codes as they are not accurate.
* Some insurance companies will not pay for any procedure that uses these codes.
 
This is NOT medical advice, just my own targets for the main blood levels I watch.
 
Protein:                7's
Albumin:               4's
Pre-Albumin:       20-30's
Iron:                     80-100
Ferritin:               200-300
HGB:                    12+
HCT:                     36+
Vit A:                    60- 80
Vit D:                    80-120
Calcium:               9.0-9.4
PTH:                     20-40
Vit B1:                 Mid to top of range
Vit B6:                 Mid to top of range
Magnesium:        Mid range (but also go by if we have leg/foot cramping)
Zinc:                    Mid range
Vit B12:               1000 +
Folate:                Top of range 20
AST (sgot):          Below 40
ALT (sgpt):           Below 40
 
 
We usually want to "meet or beat" pre-op levels. In some cases, higher is better, and in other cases

thanks, CL.....   i appreciate the lists...  I'm conparing it to what I had drawn, and there are some we didn't do....  (I had just listed the abnormals on OH)...  i hadn't had the phosphorus, osteocalcin, pre-albumin, PTH or PTT...so back I go tonight....  the doc can see me, so I can get a script  (my insurance co still pays for blood work).  From the second group, I need the LDH, MMA cortisol and homocysteine...others were within norms....

I'll keep on top of him until we figure this out!!!    Thanks,  Mary

do you see a Hemotologist?  High B12, no problem.  What was your B6?  get a PTH done  You can add your night time zinc to the afternoon one.  Ionized calcium tells more  than serum calcium  Extra protein and calcium citrate will be good...

I haven't seen a hemotologist since 2008.  we did a bone marrow biopsy, because they just couldn't figure out the anemia....  he REALLY wanted to rule out all the horrible possibilities, and , at the time, I was so sick, I figured why not?  We ruled out all the serious stuff, and decided we were unable to figure it out, but as long as I stayed around 9.5-10.5, I seemed to function quite well.  My B1 was 170, but we didn't do a B6...   I'll ask tonight...   and also about the ionized calcium...   I have only taken Ca citrate since the DS, and this was my first set of labs that was low in that...  Damn....    I had some wound healing problems after a hernia repair, and my hair was falling out, so we upped the Zinc, and I never moved it...   Can I take that much at once?  (100mg) or does it have to be divided doses?
     Hats off to all the Vitamin guru's out here that have educated the rest of us....  and continue to do so....  I truly hate to email vitalady with every crazy question....  there's so many of us, and only one of her!!!!  
   Thanks,  Mary

Just a few things I want to mention. Most B vitamins can be in the upper range, and that's good. What we don't need, we can pee out. There has been some controversy over B6 though, and that is in some of our supplements in addition to just the B-complex. The costco/kirkland brand of calcium citrate has a few bonus things, which I thought was good, until my b-6 (which it has) was off the charts. Do some reading on high B-6 - It is sounding less benign than the other b vitamins.

Also, there are more absorbable types of calcium that some of us are adding to our supplements to combat osteopenia or worse. Look up calciums hydroxy apatite or microcrystaline hydroxyapatite, as well as calcium bisglycinate. There are all better absorbed than regular citrate, but are also more expensive, which is worth it if your bones are at risk.

You need to add at least an extra 150-200g+ of protein a day until your protein numbers come up and stay up. If your protein doesn't come up the edema will just get worse and you will eventually end up on TPN.

Don't even bother with more food, you're too far behind. Go directly to supplements, shots, shakes, etc, on top of what your currently consuming.

The calcium is a concern too, but you may find everything is screwed up until you get your protein levels back up and your fluid balance restored.

thanks for the protein range to shoot for....  I am a champion eater....  and , although it tastes to me like , well, monkey butt, I can down a protein shake when the need arises.  Apparently, it arose a bit before I realized!   Cheers!   Drinking one as I type....   I just thought I was getting enough from food this far out, and still checking grams every once in a while on Sparkpeople to make sure....  sigh....    Thanks,  and I'll let you all know when I get the numbers up!!  Mary

If I were you I would over compensate on the shakes and do at least 5 a day.  I would mix it up and do different types of shakes so as to not get bored:  ready to drinks, fruity types, coffee drinks, cake shakes, whatever you can find. 

~Becky

 You have a large cell anemia which may be related to low folate. Do you take folate? Did you get a folate level?
You need to increase your protein