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Last Updated 12/17/17

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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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Phosphorus Control by Dietary Restriction May Lead to Malnutrition - Article from Renal & Urology News. - December 13, 2017

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Racial Variations in the Markers of Mineral Bone Disorders in Chronic Kidney Disease Patients in South Africa - Article in Press abstract and full-text article (31-page pdf) from Kidney International Reports. - December 12, 2017

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Old and New Calcimimetics for Treatment of Secondary Hyperparathyroidism: Impact on Biochemical and Relevant Clinical Outcomes - Free, full-text, Advance Article from Clinical Kidney Journal. - December 8, 2017

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Stuck in a Bind With Phosphate Binders - Free, full-text, Article in Press from American Journal of Kidney Diseases. - December 7, 2017

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Achieve Your Goals Together. The Easy and Reasonable Way to Treat Chronic Kidney Disease-Mineral Bone Disorder - Free, full-text, Issue-in-Progress editorial and related abstract from Blood Purification. - December 7, 2017

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PTH After Parathyroidectomy Indicates 5-Year PTH Outcomes - Article from Renal & Urology News. - December 6, 2017

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The Effect of Extended Release Niacin on Markers of Mineral Metabolism in CKD - CJASN Express abstract. - December 5, 2017

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Factors Associated with Calcium Requirements after Parathyroidectomy in Chronic Kidney Disease Patients - First Online Abstract from International Urology and Nephrology. - December 2, 2017

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Magnesium and Risk of Hip Fracture among Patients Undergoing Hemodialysis - JASN Express abstract. - November 30, 2017

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Ethanol Ablation Therapy Feasible for SHPT - Article from Renal & Urology News. - November 30, 2017

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CMS Finalizes Rule to Cancel Bundled Payment Models for Cardiac and Hip/Femur Fracture Treatments - News brief from AHANews. CMS press release. - November 30, 2017

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Phosphate-Binder Use in US Dialysis Patients: Prevalence, Costs, Evidence, and Policies - Article in Press abstract from American Journal of Kidney Diseases. - November 28, 2017

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Kidney Disease Drug (Phosphate Binders) Recommended by Nice 'May Do More Harm Than Good' - Article from The Guardian (UK). National Institute for Health and Care Excellence (Nice) search results page for phosphate binders. - November 24, 2017

David Wheeler, professor of kidney medicine at University College London and co-chair of Kdigo, said he did not think Nice's recommendation of calcium-based phosphate binders as the first-line drug was based on evidence.

"My own view is that if non-calcium based binders were as cheap as calcium based binders, we would only be using non-calcium based binders," he said.

But, Wheeler added, while non-calcium based phosphate binders are less likely to cause problems of calcium build-up in blood vessels, even for these drugs there is a dearth of evidence that they improve patient outcomes, and that clinical trials comparing the different types of drug with each other, and with a placebo, were crucial.

Editor's note: Did Tassin patients take phosphate binders?
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Association between Extreme Values of Markers of Chronic Kidney Disease: Mineral and Bone Disorder and 5-Year Mortality among Prevalent Hemodialysis Patients - Free, full-text, Issue-in-Progress article and Cappuccino with Claudio Ronco from Blood Purification. - November 22, 2017

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Association between Extreme Values of Markers of Chronic Kidney Disease: Mineral and Bone Disorder and 5-Year Mortality among Prevalent Hemodialysis Patients - Issue-in-Progress Abstract from Blood Purification. - November 22, 2017

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Hip Fracture Trends in Japanese Dialysis Patients, 2008-2013 - Article in Press Abstract from American Journal Of Kidney Diseases. - November 20, 2017

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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

  Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease in Children
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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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Well Nourished Patient topic page from RenalWEB
aluminum and dialysis (PUBMED Search) Continually Updated!
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E-mail to RenalWEB on the Bone Disease Management Topic
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