BONE MINERAL DISEASE

Definition
Types of bone disease
Predominant hyperparathyroid-mediated high-
turnover 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, 2008
VASCULAR CALCIFICATION
VASCULAR CALCIFICATION
Calcium/Phosphate
KDIGO recommend dialysate calcium
concentration 1.25 -1.5 mmol/l ( 2.5-3.0 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
Phosphate: 1.13-1.78 (3.5-5.5) GFR<15


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 minimize further calcification
by lowering the serum calcium and phosphate concentrations
Otherwise unexplained symptomatic myopathy.
PTH should > 800
Issues I did not touch on is:
Osteoporosis in CKD and Dialysis and
Management

Thank you