Recommended calcium intake in adults and children with chronic kidney disease—a European consensus statement

Abstract

Mineral and bone disorders (MBD) are common in patients with chronic kidney disease (CKD), contributing to significant morbidity and mortality. For several decades, the first-line approach to controlling hyperparathyroidism in CKD was by exogenous calcium loading. Since the turn of the millennium, however, a growing awareness of vascular calcification risk has led to a paradigm shift in management and a move away from calcium-based phosphate binders. As a consequence, contemporary CKD patients may be at risk of a negative calcium balance, which, in turn, may compromise bone health, contributing to renal bone disease and increased fracture risk. A calcium intake below a certain threshold may be as problematic as a high intake, worsening the MBD syndrome of CKD, but is not addressed in current clinical practice guidelines. The CKD-MBD and European Renal Nutrition working groups of the European Renal Association (ERA), together with the CKD-MBD and Dialysis working groups of the European Society for Pediatric Nephrology (ESPN), developed key evidence points and clinical practice points on calcium management in children and adults with CKD across stages of disease. These were reviewed by a Delphi panel consisting of ERA and ESPN working groups members. The main clinical practice points include a suggested total calcium intake from diet and medications of 800–1000 mg/day and not exceeding 1500 mg/day to maintain a neutral calcium balance in adults with CKD. In children with CKD, total calcium intake should be kept within the age-appropriate normal range. These statements provide information and may assist in decision-making, but in the absence of high-level evidence must be carefully considered and adapted to individual patient needs.

Changes in High Resolution peripheral Quantitative Computed Tomography in adolescents undergoing a first kidney transplantation.

“…These ndings are probably due to a very rigorous control of mineral biomarkers pretransplantation, notably for PTH (1.9 ULN) and phosphate levels (0.5SDS), as illustrated by the data obtained "randomly at the time of transplantation in patients receiving mostly transplants from deceased donors and therefore being drawn "without notice" in these patients. More than that, the strict nutritional control in pre-dialysis and dialysis, mainly focusing on calcium intake as recommended in international guidelines [40][41] likely provides more calcium intake than in healthy adolescent. We previously showed in our Vitados cohort a signi cant proportion of calcium de ciency, the median (range) calcium intake in this cohort indeed being of 812 (132-1382) mg [22].…”

Managing Osteoporosis in Dialysis—A Medical Catch-22

“…These recommendations seem prescient for dialysis patients receiving denosumab. Indeed, denosumab-induced hypocalcemia may be a marker of negative calcium balance . Furthermore, risk of hypocalcemia cannot be addressed without considering nephrologists’ role in coordinating care and ensuring patient safety.…”

“…Even “hidden” hypocalcemia, defined as low ionized calcium despite normal or high albumin-corrected calcium, occurs in up to 61% of dialysis patients and is associated with a remarkable 156% increased risk of death and cardiovascular events . These data collectively prompted several working groups of the European Renal Association and the European Society for Pediatric Nephrology to publish a consensus statement recommending the maintenance of a neutral calcium balance. These recommendations seem prescient for dialysis patients receiving denosumab.…”

Denosumab-induced hypocalcemia in patients treated with dialysis: an avoidable complication?

“…This notion is supported by calcium isotope studies documenting skeletal calcium efflux in dialysis patients on a regular diet, even when treated with calcium supplements [ 4 ]. A recent consensus statement by the European Renal Association and the European Society of Paediatric Nephrology recommends a daily calcium intake of 800–1000 mg in patients with CKD to maintain neutral calcium balance [ 5 ]. In severe hyperparathyroidism, bone is in a calcium deficit and will rapidly re-mineralize when PTH levels decrease.…”

“…In severe hyperparathyroidism, bone is in a calcium deficit and will rapidly re-mineralize when PTH levels decrease. A temporary higher calcium supply is therefore often appropriate following PTH suppressive or antiresorptive therapy [ 5 ].…”