BONE MINERAL DISEASE

Definition

Types of bone disease

Predominant hyperparathyroid-mediated highturnover bone disease (osteitis fibrosa [OF])
Low-turnover osteomalacia (defective mineralization
in association with low osteoclast and osteoblast
activities)
Mixed uremic osteodystrophy (MUO;
hyperparathyroid bone disease with a superimposed
mineralization defect)
Osteomalacia (defined as a mineralization lag time
>100 days).
Adynamic bone (diminished bone formation and
resorption)

Prevalance of types of bone disease as

determined by bone biopsy in patients with
CKD-MBD

AD, adynamic bone; OF, osteitis fibrosa; OM, osteomalacia.

Risk of all-cause mortality associated with

combinations of baseline serum phosphorus and
calcium categories by PTH level (from DOPPS)

Tentori F, et al. AJKD 52: 519,

VASCULAR CALCIFICATION

VASCULAR CALCIFICATION

Calcium/Phosphate
KDIGO recommend dialysate calcium
concentration 1.25 -1.5 mmol/l ( 2.53.0 meq/l)
KDOQI : 2.5meq
KDOQI : Total calcium should be
maintain 2.2-2.37 mmol (8.8 -9.5). If
calcium > 2.54 ( 10.2)something
needs to be done
Phosphate; 0.87-1.49 (2.7-4.6)mg/dl
GFR 15-59

PTH
KDOQI :
eGFR 30-59 : 35-70
eGFR 15-29: 70-110
eGFR <15: 150-300 (16.5 -33.0)
KDIGO : 2-9 upper limit of normal
values

Treatment

Calcium
Phosphate Binders
Vitamin D
Cinnacalcet
Parathyroidectomy

Calcium based binders

Calcium acetate more efficient
phosphate binder than calcium
carbonate
Calcium carbonate dissolve only at
acid pH and many patients have low
acid levels or on antiacids
Total dose of elementary calcium
( include dietary) should not exceed
2000mg. For binders should exceed
1500mg

Vitamin D

Zheng et al. BMC Nephrology 2013, 14 :199

THE LANCET: Effect of calcium

based versus non-calcium based
phosphate binders on martality in
patients with chronic kidney
disease : systemic review and
meta-analysis

Cinnacalcet
Lowers PTH levels by increasing the
sensitivity of the calcium-sensing
receptor to extracellular calcium

Figure 1. Flow chart showing number of citations retrieved by database

searching, and the trials included in this review.

Palmer SC, Nistor I, Craig JC, Pellegrini F, et al. (2013) Cinacalcet in Patients with Chronic Kidney Disease: A
Cumulative Meta-Analysis of Randomized Controlled Trials. PLoS Med 10(4): e1001436.
doi:10.1371/journal.pmed.1001436
http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001436

Advance
study

Evolve Study

Parathyroidectomy
Severe hypercalcemia.
Progressive and debilitating hyperparathyroid
bone disease as defined by radiographic or
histologic evaluation.
Pruritus that does not respond to medical or
dialytic therapy.
Progressive extraskeletal calcification or
calciphylaxis that is usually associated with
hyperphosphatemia that is refractory to oral
phosphate binders. In this setting, PTH-induced
release of phosphate from bone contributes to the
persistent elevation in the serum phosphate
concentration. Parathyroidectomy will tend to

Issues I did not touch on is:

Osteoporosis in CKD and Dialysis and
Management
Thank you