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Last Updated 09/23/18
 

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Unless closely monitored, renal bone disease (renal osteodystrophy) is a problem that will be experienced by most people suffering from end stage renal disease (ESRD). Renal bone disease is a complex issue and involves many more factors than can be listed in this limited space. Only the very basics are outlined here.

First, the kidneys are involved in the synthesis of vitamin D, which is the most essential factor regulating intestinal absorption of calcium in humans. When the kidneys fail and less vitamin D is created, the amount of calcium absorbed by the intestines is reduced. Calcium is most essential substance for bone maintenance and health. Next, calcium and phosphorus levels in the blood (which are normally regulated by the kidneys) are dependent upon each other. Therefore, when the kidneys fail and the phosphorus level in the blood goes up, the (free) calcium level in the blood decreases. In response to these two factors that lower serum calcium, the body then increases the parathyroid hormone (PTH) level in the blood.  PTH causes calcium to be released from the bones in order to increase the serum calcium level.  Left untreated, an ESRD patient will have bones that are depleted of calcium, brittle, and likely to fracture.

Treatment and prevention of renal bone disease usually include the use of phosphate binders and vitamin D analogs (to reduce PTH levels).  In the past, treatment frequently included the removal of the parathyroid glands.

Normal serum calcium is 8.5-10.8 mg/dL.

Normal serum phosphorus for dialysis patients is 3.5 to 5.5 mg/dl High phosphorus levels also cause itchy skin.

It is recommended that ESRD patients maintain a calcium phosphorous product that is below 70.

Warning:  Changes should never be made in a patient's treatment or care based solely on the information found here.  Every patient has unique healthcare concerns and considerations and all these factors must all be taken into account before any changes can be safely made.  All medical and therapeutic decisions must come from a qualified health care provider.  Read RenalWEB's Legal Disclaimer before proceeding.


  NEWS AND LATEST INFORMATION
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Renal Association Commentary on the KDIGO (2017) Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of CKD MBD - Free, Open Access Article from BMC Nephrology. - September 20, 2018

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Role of Albumin Assay on Calcium Levels and Prescription of Phosphate Binders in Chronic Hemodialysis Patients - Free, Open Access, Online First article from Nephron. - September 13, 2018

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Cinacalcet As Rescue Therapy for Refractory Hyperparathyroidism in Young Children with Advanced Chronic Kidney Disease - First Online abstract from Pediatric Nephrology. - September 10, 2018

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Relative Prognostic Impact of Nutrition, Anemia, Bone Metabolism and Cardiovascular Comorbidities in Elderly Hemodialysis Patients - Advance Articles Abstract from NDT. - September 8, 2018

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High-Serum Phosphate and Parathyroid Hormone Distinctly Regulate Bone Loss and Vascular Calcification in Experimental Chronic Kidney Disease - Advance Articles Abstract from NDT. - September 5, 2018

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Vitamin D, Bone Alkaline Phosphatase and Parathyroid Hormone in Healthy Subjects and Hemodialyzed Patients from West Africa: Impact of Reference Ranges and Parathyroid Hormone Generation Assays on the KDIGO Guidelines - Free, full-text, Advance Article from Clinical Kidney Journal. - September 5, 2018

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PTH Assays in Dialysis Patients: Practical Considerations - Early View abstract from Seminars in Dialysis. - August 30, 2018

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Pharmacodynamics of Evocalcet for Secondary Hyperparathyroidism in Japanese Hemodialysis Patients - Free, Open Access, First Online article from Clinical and Experimental Nephrology. - August 29, 2018

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Overview of the 2017 KDIGO CKD-MBD Update: Practice Implications for Adult Hemodialysis Patients - Free, full-text, Article in Press from Journal of Renal Nutrition. - August 23, 2018

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An Open Label, Single-Dose Study to Evaluate the Safety, Tolerability, Pharmacokinetics, and Pharmacodynamics of Cinacalcet in Pediatric Subjects Aged 28 Days to < 6 years with Chronic Kidney Disease Receiving Dialysis - Free, Open Access, First Online article from Pediatric Nephrology. - August 23, 2018

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Phosphorus Content of Prescription Medications - Posting from the NephronPower blog. - August 21, 2018

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The Man Who Sold America On Vitamin D — And Profited In The Process - Article from Kaiser Health News. - August 20, 2018

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Predictors of Bone Fractures in a Single-Center Cohort of Hemodialysis Patients: a 2-Year Follow-Up Study - First Online abstract from International Urology and Nephrology. - August 16, 2018

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Phosphate Control May Reduce FGF23 Levels in HD - Article from Renal & Urology News. - August 16, 2018

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  WEB RESOURCES
blue ball Latest Scientific Journal Articles on Bone Disease Continually Updated!
Bone Density Studies Benefits Brochure (pdf format requires Adobe Acrobat reader)  from the Centers for Medicare & Medicaid Services (CMS)
National Institutes of Health Osteoporosis and Related Bone Diseases - National Resource Center web site
Bone Disease from the Kidney Patient Guide web site of the UK
blue ball Bone and Mineral Metabolism - this is a growing library of key high-impact articles in nephrology, chosen by UKidney's contributors as suggested reading for nephrology trainees and practitioners.
AAKP Nutrition Coundter: A Reference for the Kidney Patient from the American Association of Kidney Patients web site
Chronic Kidney Disease Mineral and Bone Disorder in Children - full-text educational feature from Pediatric Nephrology
Mineral and Bone Disorder in CKD Stage 3 and 4 from the National Kidney Foundation web site
Renassist is a value-added program provided to patients to assist them in determining how they can access Renagel through their current health insurance from the Genzyme web site
Drug and Supplements Info: Calcium Carbonate from NLM MedLine Plus 
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  ESSENTIALS AND CLASSICS
Bone Mineral Metabolism Fact Sheet (pdf format requires Adobe Acrobat reader.) from the American Nephrology Nurses’ Association
Chronic Kidney Disease-Mineral and Bone Disorder - from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) web site
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Washington University Nephrology Web Episode - Bone Mineral Metabolism - Video from the Renal Fellow Network blog. 

Renal Osteodystrophy Topic from MedicineNet.com
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  PUBMED SEARCHES (National Library of Medicine's MEDLINE Database)
osteodystrophy AND dialysis   Continually Updated!
bone disease AND dialysis   Continually Updated!
phosphate binder   Continually Updated!
hyperparathyroidism AND dialysis    Continually Updated!
secondary hyperparathyroidism   Continually Updated!
MEDLINE / Pubmed Information from the National Library of Medicine
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  K/DOQI™ -  Kidney Disease Outcomes Quality Initiative
Clinical Practice Guidelines For Chronic Kidney Disease
 

  Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease
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  KDIGO™ -  Kidney Disease: Improving Global Outcomes
Clinical Practice Guidelines: Table of Contents
 

 

Clinical Practice Guideline for CKD-Mineral and Bone Disorder (CKD-MBD) (Published 2017)


  WEB SEARCH ENGINES
Renal Osteodystrophy-related web pages by Yahoo! Continually Updated!
Renal Osteoporosis-related web pages by Yahoo! Continually Updated!
Renal Osteoarthritis-related web pages by Yahoo! Continually Updated!
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  DISCUSSION FORUM
General Dialysis Nursing Issues and Questions (No dedicated RenalWEB forum yet for this topic)
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  PRODUCTS
PHOSLYRA (calcium acetate oral solution) solution by Fresenius Medical Care North America
RenVela® Tablets (sevelamer) - phosphate binder
Hectorol™ Capsules (vitamin D analog for treating secondary hyperparathyroidism)
Rocaltrol ® brand of (calcitrol) Capsules and Oral Solution (vitamin D analog) - Product Information
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  RELATED TOPICS
Well Nourished Patient topic page from RenalWEB
aluminum and dialysis (PUBMED Search) Continually Updated!
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  INPUT / SUGGESTIONS
E-mail to RenalWEB on the Bone Disease Management Topic
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