Management of chronic kidney disease mineral bone disorder (CKD-MBD) in the United States has grown more conservative and variable in recent years, according to new data.

From 2006 to 2015, vitamin D sterol prescriptions decreased and cinacalcet use or no use of parathyroid hormone-modifying agents increased, according to records from 23,549 patients initiating hemodialysis at Dialysis Clinic, Inc., facilities across the United States. Patients were more likely to receive phosphate binders alone or no mineral metabolism medications, Julia J. Scialla, MD, of Duke University School of Medicine in Durham, North Carolina, and colleagues reported in the Clinical Journal of the American Society of Nephrology.  

The proportion of patients using active vitamin D sterol-based strategies at dialysis initiation decreased from 15% during 2006-2008 to 5% during 2012-2015. Use of active vitamin D sterols after 18 months of dialysis decreased from 52% to 34%, respectively, even when indexed to specific parathyroid hormone thresholds.

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The researchers also observed longer dialysis sessions over time, but could not fully assess this practice, dialysate calcium concentration, or dietary phosphate restriction.

Dr Scialla and her collaborators found increased variation in strategies across facilities over time. Individual strategies included use of cinacalcet, vitamin D, or a phosphate binder alone or no mineral metabolism medication. The median odds of using one of these individual strategies rather than an active vitamin D sterol plus phosphate binder varied 1.5- to 2-fold across facilities during 2006-2008 and 2009-2011, and increased to approximately 2- to 3-fold during 2012–2015. Strategies varied even when PTH levels exceeded 300 pg/mL.

Notably, guideline-based biochemical targets were relaxed in 2009. Vitamin D sterols were incorporated into the dialysis payment bundle in 2011, whereas cinacalcet and phosphate binders remained outside of the bundle up to 2015. The Quality Incentive Program hypercalcemia performance measure in 2014 was associated with less vitamin D sterol prescription.

“These changes may not be simply attributable to payment-model changes in hemodialysis, but also to changes in guidelines and the nephrology community’s beliefs about the relative risks and benefits of intensively managing mineral metabolism,” Dr Scialla’s team wrote.“The growing equipoise is an opportunity for natural experiments and randomized controlled trials to build the evidence base that is needed in nephrology for stronger, evidence-based recommendations in this important area in hemodialysis care.”

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


Hall R, Platt A, Wilson J, et al. Trends in mineral metabolism treatment strategies in patients receiving hemodialysis in the United States. Clin J Am Soc Nephrol. 2020;15:1603-1613. doi:10.2215/CJN.04350420