A Kidney Disease: Improving Global Outcomes (KDIGO) work group has just released an update of the KDIGO Clinical Practice Guideline for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder (CKD-MBD).

Much of the advice remains the same from the 2009 guidelines. However, the work group revised their recommendations in key areas dealing with diagnosis of bone abnormalities, treatment by targeting phosphate lowering and calcium adequacy, treatment of parathyroid hormone (PTH) abnormalities, treatment of bone abnormalities by antiresorptives and other osteoporosis therapies, and evaluation and treatment of kidney transplant bone disease. The updated guidelines were published in Kidney International.

“The largest shift is a more forceful general attitude towards avoiding hypercalcemia and calcium overload,” commented Csaba P. Kovesdy, MD, Chief of Nephrology at the Memphis VA Medical Center and Fred Hatch Professor of Medicine at the University of Tennessee Health Science Centers in Memphis, who was not involved in the update. “This has resulted in new recommendations to avoid calcium-based binders in general and active vitamin D or vitamin D analogues in patients with CKD not on dialysis. Moving away from calcium-based therapies for phosphate binding is a step in the right direction.”

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“The recommendation for avoidance of active vitamin D in pre-dialysis CKD is more controversial in my opinion,” continued Dr Kovesdy, who is a member of the Renal & Urology News editorial advisory board. “While it is true that the available clinical trial data did not show clinical benefits and that a small risk of hypercalcemia exists, this guideline update does not offer alternatives. Native forms of vitamin D will likely be used going forward, even though they show inferior efficacy to lower PTH and have also not been shown to achieve any clinical benefits in this group.”

He added that revisiting the role of dual energy X-ray absorptiometry in the evaluation of bone disease is a positive development, although the lack of accepted therapies in this patient population will limit its effect considerably.

For the update, the 20-member work group performed systematic reviews of recent randomized controlled trials and prospective cohort studies using the GRADE (grading of recommendations, assessment, development, and evaluations) approach. “Not graded” recommendations were based on opinion.

Among other provisions, the guidelines suggest:

  • Patients with CKD stage 3a–5 not on dialysis who have levels of intact PTH progressively rising or persistently above the upper normal limit for the assay be evaluated for modifiable factors, including hyperphosphatemia, hypocalcemia, high phosphate intake, and vitamin D deficiency.
  • Calcitriol and vitamin D analogues not be used routinely for adult patients with CKD stages 3a– 5. It is reasonable to reserve the use of calcitriol and vitamin D analogues for patients with CKD stage 4–5 with severe and progressive hyperparathyroidism.
  • Using calcimimetics, calcitriol, or vitamin D analogues, or a combination of calcimimetics with calcitriol or vitamin D analogues for patients with CKD stage 5D requiring PTH-lowering therapy.
  • Bone mineral density testing to assess fracture risk if results will impact treatment decisions in patients with CKD stage 3a–5D. It is reasonable to perform a bone biopsy if knowledge of the type of renal osteodystrophy will impact treatment decisions, according to the guidelines.
  • Basing CKD-MBD treatments for patients with CKD stage 3a–5D on serial assessments of phosphate, calcium, and PTH levels, considered together.
  • Lowering elevated phosphate levels toward the normal range in patients with CKD stage 3a–5D.
  • Avoiding hypercalcemia in adult patients with CKD stage 3a–5D.
  • Using dialysate calcium concentration between 1.25 and 1.50 mmol/L (2.5 and 3.0 mEq/L) in patients with CKD stage 5D.

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Ketteler M, Block GA, Evenepoel P, et al. Executive summary of the 2017 KDIGO Chronic Kidney Disease–Mineral and Bone Disorder (CKD-MBD) Guideline Update: What’s Changed and Why It Matters. Kid Intl 92;26–36. doi: 10.1016/j.kint.2017.04.006