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Last Updated 07/15/18

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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.

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Metformin Prevents the Development of Severe Chronic Kidney Disease and Its Associated Mineral and Bone Disorder - CKD Free, Full-Text Article from Kidney International. - July 2018

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Phosphate Binders Derived from Natural Ores Contain Many Kinds of Metallic Elements Besides Their Active Ingredient Metals - Early View Abstract from Therapeutic Apheresis and Dialysis. - July 10, 2018

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Phosphate Control Adherence in Hemodialysis Patients: Current Perspectives - Abstract and link to full-text article (17-page PDF) from Patient Preference and Adherence. - July 5, 2018

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Phosphate Binders As a Cause of Hypothyroidism in Dialysis Patients: Practical Indications from a Review of the Literature - Free, Open Access article from BMC Nephrology. - July 2, 2018

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Clinical Experience with the Use of Ferric Citrate As a Phosphate Binder in Pediatric Dialysis Patients - First Online abstract from Pediatric Nephrology. - June 28, 2018

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Free, Full-Text Articles from the Journal of the American Medical Association - June 26, 2018

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Evidence Basis for Integrated Management of Mineral Metabolism in Patients With End-Stage Renal Disease - (Registration required, but free.) Free full-text article from Current Opinion in Nephrology and Hypertension via Medscape Nephrology. - June 21, 2018

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Intradialytic Alkalinization Is a Neglected Factor Affecting Calcium Mass Balance and Parathyroid Hormone Level during Hemodiafiltration - Free, Full-Text, Advance Articles from Clinical Kidney Journal - June 21, 2018

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Dramatic Regression of Parathyroid Gland Swelling After Conversion of Calcimimetic Medication From Cinacalcet to Etelcalcetide - Early View, Open Access letter to the editor from Therapeutic Apheresis and Dialysis. - June 21, 2018

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Effects of Lowering Dialysate Calcium Concentration on Bone Metabolic Markers in Hemodialysis Patients With Suppressed Serum Parathyroid Hormone: A Preliminary Study - Early View Abstract from Therapeutic Apheresis and Dialysis. - June 20, 2018

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Free, Open Access Articles from PLOS One - May 24-June 18, 2018

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Online First Abstracts from Nephron - April 19-June 7, 2018

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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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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
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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)

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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General Dialysis Nursing Issues and Questions (No dedicated RenalWEB forum yet for this topic)
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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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aluminum and dialysis (PUBMED Search) Continually Updated!
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