Foreword

Abstract

The 2009 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline on the management of chronic kidney disease-mineral and bone disorder (CKD-MBD) is intended to assist the practitioner caring for adults and children with CKD stages 3-5, on chronic dialysis therapy, or with a kidney transplant. The guideline contains recommendations on evaluation and treatment for abnormalities of CKD-MBD. This disease concept of CKD-MBD is based on a prior KDIGO consensus conference. Tests considered are those that relate to the detection and monitoring of laboratory, bone, and cardiovascular abnormalities. Treatments considered are interventions to treat hyperphosphatemia, hyperparathyroidism, and bone disease in patients with CKD stages 3-5D and 1-5T. The guideline development process followed an evidence based approach and treatment recommendations are based on systematic reviews of relevant treatment trials. Recommendations for testing used evidence based on diagnostic accuracy or risk prediction and linked it indirectly with how this would be expected to achieve better outcomes for patients through better detection, evaluation or treatment of disease. Critical appraisal of the quality of the evidence and the strength of recommendations followed the GRADE approach. An ungraded statement was provided when a question did not lend itself to systematic literature review. Limitations of the evidence, especially the lack of definitive clinical outcome trials, are discussed and suggestions are provided for future research.

Retracted: Bone Mineral Density Predicts Fractures in Chronic Kidney Disease

“…Indeed, it was because of the lack of data on BMD and fracture in CKD that the 2009 Kidney Disease Improving Global Outcomes guidelines (section 3.2.2) in part stated the following: "In patients with stages 3 to 5D CKD with evidence of CKD MBD, we suggest that BMD testing not be performed routinely…." (30) As a result, patients with CKD and clinicians taking care of them have largely ignored fracture risk assessment in CKD. Our prospective data suggests BMD by DXA, as well as bone loss noted over follow-up, are informative in anticipating fractures among patients with predialysis CKD.…”

Extracellular Fluid Excess Is Significantly Associated With Coronary Artery Calcification in Patients With Chronic Kidney Disease

“…Some studies have reported that calcium, phosphate, and parathyroid hormone, as well as dialysis, promote CAC; however, other studies failed to demonstrate such relationships 44. In this study, although the levels of calcium and phosphate tended to deteriorate with the progression of renal failure, they were in the normal range suggested by clinical guidelines,45, 46 even in patients with advanced CKD (Table S1), and we failed to identify the association between mineral parameters and the presence of CAC (data not shown). Despite some studies showing that phosphate level increases in CAC within the normal range,47 the Kidney Disease: Improving Global Outcomes and Kidney Disease Outcomes Quality Initiative guidelines do not recommend phosphate lowering in patients with CAC in the normal range 45, 46.…”

What is the optimal level of vitamin D in non-dialysis chronic kidney disease population?

“…As a result of these findings, current guidelines have suggested VD supplementation in CKD patients [18][19][20][21] , increasing VD supplementation rates among this population [22] . Nevertheless, these recommendations are opinion based and the optimal VD levels as well as the upper safe limit of VD intakes remains controversial [23,24] .…”

“…Nevertheless, these recommendations are opinion based and the optimal VD levels as well as the upper safe limit of VD intakes remains controversial [23,24] . Based on the inverse relationship between serum concentrations of 25(OH)D and parathyroid hormone (PTH), most current guidelines have defined VD deficiency and insufficiency, as a serum 25(OH)D level of < 20 ng/mL (50 nmol/L) and 20-29 ng/mL (52-72 nmol/L) respectively [18,19] , suggesting a serum concentration of 25(OH)D above 30-40 ng/mL Molina P et al . Estimating optimal vitamin D status in CKD (75-100 nmol/L) to be desirable, levels at which PTH is suppressed to a minimum in its relation to 25(OH)D [25,26] .…”

“…These criteria vary among authors and societies, including 25(OH)D levels below which osteomalacia [10 ng/mL (25 nmol/L)] or secondary hyperparathyroidism [20-30 ng/mL (50 to 75 nmol/L)] may appear [18][19][20]35,36] . Being aware of their potential clinical significance, the present study examines the prognosis value of 25(OH)D levels in a cohort of 3-5 stage CKD subjects not on dialysis, trying to identify cut-off points for serum 25(OH)D levels to define VD sufficiency.…”