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Chronic kidney disease-mineral and bone disorder

Background

Overview

Definition
CKD-MB is a systemic disorder of mineral and bone metabolism due to CKD.
1
Pathophysiology
The injured kidney produces circulating signals that directly affect the vasculature, myocardium, and skeleton.
2
Epidemiology
Among patients with ESRD undergoing dialysis, the prevalence of CKD-MB is up to 86%.
3
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.
1
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.
2

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.
C
Consider measuring 25-hydroxyvitamin D levels in patients with CKD stages 3-5D and repeat testing determined by baseline values and therapeutic interventions.
C
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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.
C
Consider performing a bone biopsy in patients with CKD stages G3a-G5D if knowledge of the type of renal osteodystrophy will impact treatment decisions.

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.
B
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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.
B
Take into account phosphate sources (such as animals, vegetables, and additives) in making dietary recommendations.

Therapeutic procedures

Percutaneous ethanol injection therapy: as per JSDT 2013 guidelines, consider offering selective percutaneous ethanol injection therapy if only one parathyroid gland is enlarged and is located at a puncturable site.

Surgical interventions

Indications for parathyroidectomy: as per KDIGO 2017 guidelines, consider performing parathyroidectomy in patients with CKD stages 3-5D with severe hyperparathyroidism failed to respond to pharmacological therapy.
C

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.
B

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  • Kidney transplant recipients

  • Patients with vascular calcifications

  • Patients with dialysis-associated amyloidosis

Follow-up and surveillance

Serial laboratory monitoring, non-transplant: as per KDIGO 2017 guidelines, monitor serum levels of calcium, phosphorus, PTH, and ALP activity beginning in CKD stage 3.
B

More topics in this section

  • Serial laboratory monitoring (post-transplant)