Table of contents
Chronic kidney disease-mineral and bone disorder
Background
Overview
Definition
CKD-MB is a systemic disorder of mineral and bone metabolism due to CKD.
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Pathophysiology
The injured kidney produces circulating signals that directly affect the vasculature, myocardium, and skeleton.
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Epidemiology
Among patients with ESRD undergoing dialysis, the prevalence of CKD-MB is up to 86%.
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Disease course
CKD-MB manifests as abnormalities of calcium, phosphorus, PTH, or vitamin D metabolism; abnormalities in bone turnover, mineralization, volume, growth, or strength; and vascular or other soft-tissue calcification.
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Prognosis and risk of recurrence
Disruptions in bone architecture increase the risk of fracture, while vascular calcification promotes the development of LVH, contributing to the excess cardiovascular risk and excess cardiac mortality seen in patients with CKD.
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Guidelines
Key sources
The following summarized guidelines for the evaluation and management of chronic kidney disease-mineral and bone disorder are prepared by our editorial team based on guidelines from the Japanese Society of Nephrology (JSN 2019), the Kidney Disease: Improving Global Outcomes Foundation (KDIGO 2017,2009), the Japanese Society of Dialysis Therapy (JSDT 2013), and the United Kingdom Kidney Association (UKKA 2011).
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Diagnostic investigations
Routine laboratory evaluation
As per KDIGO 2017 guidelines:
Consider measuring serum PTH or bone-specific ALP for the evaluation of bone disease in patients with CKD stages 3-5D as markedly high or low values predict underlying bone turnover.
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Consider measuring 25-hydroxyvitamin D levels in patients with CKD stages 3-5D and repeat testing determined by baseline values and therapeutic interventions.
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Bone-derived turnover markers
Bone mineral density testing
Diagnostic procedures
Bone biopsy
As per KDIGO 2017 guidelines:
Consider performing a bone biopsy in patients with CKD stages G3a-G5D with biochemical abnormalities of CKD-MB and low bone mineral density and/or fragility fractures.
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Consider performing a bone biopsy in patients with CKD stages G3a-G5D if knowledge of the type of renal osteodystrophy will impact treatment decisions.
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Medical management
General principles: as per KDIGO 2017 guidelines, base treatment decisions on trends rather than on a single laboratory value in patients with CKD stages 3-5D, taking into account all available assessments.
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Treatment targets
Management of hyperphosphatemia
Management of hyperparathyroidism
Management of hypocalcemia
Management of vitamin D deficiency
Management of osteoporosis
Nonpharmacologic interventions
Dietary phosphate restriction
As per KDIGO 2017 guidelines:
Advise limiting dietary phosphate intake, alone or in combination with other therapeutic options, in the treatment of hyperphosphatemia in patients with CKD stages G3a-G5D.
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Take into account phosphate sources (such as animals, vegetables, and additives) in making dietary recommendations.
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Therapeutic procedures
Surgical interventions
Specific circumstances
Pediatric patients: as per JSN 2019 guidelines, treat CKD-MB in pediatric patients with CKD to improve bone lesions and cardiovascular function. Consider maintaining the corrected serum levels of calcium and phosphorus within normal ranges in accordance with the patient's age.
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Kidney transplant recipients
Patients with vascular calcifications
Patients with dialysis-associated amyloidosis