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Last Updated 06/18/17
 

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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.


  NEWS AND LATEST INFORMATION
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Free, Full-Text Articles from Pediatric Nephrology - July 2017

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Effect of Tenapanor on Serum Phosphate in Patients Receiving Hemodialysis - Free, Full-Text Article from the Journal of the American Society Of Nephrology. - June 2017

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Why Current PTH Assays Mislead Clinical Decision Making in Patients with Secondary Hyperparathyroidism - Free, full-text article from Nephron. - June 2017

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Aurobindo Pharma (India) Gets USFDA Approval to Manufacture Sevelamer Carbonate - June 15, 2017

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Effect of Aerobic Exercise on Markers of Bone Metabolism of Overweight and Obese Patients With Chronic Kidney Disease - Articles in Press Abstract from Journal of Renal Nutrition. - June 13, 2017

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Improvements in MBD Lab Outcomes Associated with Improved Pharmaceutical Care in Hemodialysis Patients - Article from Nephrology News & Issues. - June 9, 2017

"Coordinated pharmacy care of mineral and bone disorder (MBD) therapies can lead to improvements in laboratory outcomes"

Editor's note: This study – once again – makes biochemical markers, rather than life outcomes, the targets of therapy.

Isn't much of the bone disease seen in dialysis patients due to inadequate dialysis? Who owns the pharmacy service?

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Treatment of Low Bone Density or Osteoporosis to Prevent Fractures in Men and Women: A Clinical Practice Guideline Update From the American College of Physicians - Free, full-text clinical guidelines from Annals of Internal Medicine. - June 6, 2017

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Positioning Novel Biologicals in CKD-Mineral and Bone Disorders - First Online Abstract from Journal of Nephrology. - May 24, 2017

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Residual Kidney Function Predicts Mortality in CKD-MBD - Article from Renal & Urology News. - May 24, 2017

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Long-Term Assessment of the Safety and Efficacy of PA21 (Sucroferric Oxyhydroxide) in Japanese Hemodialysis Patients With Hyperphosphatemia: An Open-Label, Multicenter, Phase III Study - Free, full-text, Article in Press from Journal of Renal Nutrition. - May 24, 2017

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Late Conversion from Tacrolimus to a Belatacept-based Immuno-Suppression Regime in Kidney Transplant Recipients Improves Renal Function, Acid-Base Derangement and Mineral-Bone Metabolism - First Online abstract from Journal of Nephrology. - May 24, 2017

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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
 

  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
 

  NEWClinical 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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