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Last Updated 5/12/13
 

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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

CJASN Express Abstracts - May 9, 2013
Temporal Trends in the Incidence, Treatment, and Outcomes of Hip Fracture in Older Patients Initiating Dialysis in the United States
Estimated GFR and Fracture Risk: A Population-Based Study

Effect of Cinacalcet Availability and Formulary Listing on Parathyroidectomy Rate Trends - Provisional abstract and full-text article (17-page pdf) from BMC Nephrology. Related article from Medscape Nephrology News. - May 3, 2013
"Conclusions: A reduction in rates of parathyroidectomy was found after January 2006, corresponding to cinacalcet availability. However, decreased rates may be due to other factors occurring simultaneously with cinacalcet introduction and further studies are needed to confirm these findings."

Prevention of Steroid Induced Low Bone Mineral Density in Children with Renal Diseases: a Systematic Review - Advance Access abstract from NDT. - May 2, 2013

Trends in Hip Fracture Rates in US Hemodialysis Patients, 1993-2010 - Articles in Press Abstract from American Journal Of Kidney Diseases - April 29, 2013

Fibroblast Growth Factor-23: What We Know, What We Don't Know, and What We Need to Know - Advance Access abstract from NDT. - April 25, 2013

Bone Alkaline Phosphatase in CKD–Mineral Bone Disorder - Article in Press abstract from American Journal of Kidney Diseases. - April 25, 2013

Oral Paricalcitol Reduces the Prevalence of Posttransplant Hyperparathyroidism: Results of an Open Label Randomized Trial - Early View abstract from American Journal of Transplantation. - April 19, 2013

Sclerostin: Another Bone Related Protein Related to All Cause Mortality in Hemodialysis? - Advance Access Abstract from NDT - April 19, 2013

Is There an Association between Elevated or Low Serum Levels of Phosphorus, Parathyroid Hormone, and Calcium and Mortality in Patients with End Stage Renal Disease? A Meta-Analysis - (29-page pdf) - Provisional Abstract and Full-Text Article (PDF) from BMC Nephrology - April 17, 2013

Articles in Press Abstracts from American Journal of Kidney Diseases - April 15, 2013
Dialysate Calcium Concentration and Mineral Metabolism in Long and Long-Frequent Hemodialysis: A Systematic Review and Meta-analysis for a Canadian Society of Nephrology Clinical Practice Guideline
Hyponatremia, Mineral Metabolism, and Mortality in Incident Maintenance Hemodialysis Patients: A Cohort Study

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  WEB RESOURCES
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)
The Well-Controlled Patient: Looking Beyond the Lab Tests from the National Kidney Foundation (NKF) web site
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
Na-K-Phos Counter from the American Association of Kidney Patients web site
Exercise, Bone Disease and Chronic Kidney Disease from the National Kidney Foundation (NKF) web site
Chronic Kidney Disease, Bone Disease and Nutrition from the National Kidney Foundation (NKF) web site
Chronic Kidney Disease - Mineral and Bone Disorder (pdf) free CE program from the National Kidney Foundation (NKF) web site
Chronic Kidney Disease Mineral and Bone Disorder in Children - full-text educational feature from Pediatric Nephrology
Latest Grant Applications & Guidelines - sponsored by the American Kidney Fund (AKF)
Mineral and Bone Disorder in CKD Stage 3 and 4 from the National Kidney Foundation web site

New Insights in Bone Biology - provides a virtual tour of the human skeleton and the cellular and physiological processes involved in the formation of bone from Amgen

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
Understanding High Phosporus and Your Treatment Options - (pdf) article from the American Association of Kidney Patients (AAKP)
Drug and Supplements Info: Calcium Carbonate from NLM MedLine Plus 
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  ESSENTIALS AND CLASSICS
Bone Disease Protocols and Algorithms from the ESRD Network 11 web site
Protocol for the Prevention and Management of Renal Osteodystrophy in Adult Dialysis Patients (pdf format requires Adobe Acrobat reader) from the ESRD Network 11 web site
A Team Approach to Managing Bone Disease in CKD Stage 5 (pdf) from the National Kidney Foundation web site
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
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: Table of Contents
 

  Bone Metabolism and Disease in Chronic Kidney Disease
 

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

  KDIGO Guideline for Chronic Kidney Disease -Mineral and Bone Disorder (CKD-MBD)



  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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