Bone mineral disease
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Transcript of Bone mineral disease
Types of bone disease• Predominant hyperparathyroid-mediated high-turnover
bone disease (osteitis fibrosa [OF])• Low-turnover osteomalacia (defective mineralization in
association with low osteoclast and osteoblast activities)• Mixed uremic osteodystrophy (MUO; hyperparathyroid
bone disease with a superimposed mineralization defect)• Osteomalacia (defined as a mineralization lag time >100
days).• Adynamic bone (diminished bone formation and
resorption)
Prevalance of types of bone disease as determined by bone biopsy in patients with CKD-MBD
AD, adynamic bone; OF, osteitis fibrosa; OM, osteomalacia.
Risk of all-cause mortality associated with combinations of baseline serum phosphorus and calcium categories by PTH level
(from DOPPS)
Tentori F, et al. AJKD 52: 519, 2008
Calcium/Phosphate• KDIGO recommend dialysate calcium
concentration 1.25 -1.5 mmol/l ( 2.5-3.0 meq/l)• KDOQI : 2.5meq• KDOQI : Total calcium should be maintain 2.2-
2.37 mmol (8.8 -9.5). If calcium > 2.54 ( 10.2)…something needs to be done
• Phosphate; 0.87-1.49 (2.7-4.6)mg/dl GFR 15-59• Phosphate: 1.13-1.78 (3.5-5.5) GFR<15
PTH
• KDOQI :eGFR 30-59 : 35-70 eGFR 15-29: 70-110eGFR <15: 150-300 (16.5 -33.0)• KDIGO : 2-9 upper limit of normal values
Calcium based binders
Calcium acetate more efficient phosphate binder than calcium carbonateCalcium carbonate dissolve only at acid pH and many patients have low acid levels or on antiacidsTotal dose of elementary calcium ( include dietary) should not exceed 2000mg. For binders should exceed 1500mg
THE LANCET: Effect of calcium based versus non-calcium based phosphate binders on martality in patients with chronic kidney disease : systemic review and meta-analysis
Cinnacalcet
• Lowers PTH levels by increasing the sensitivity of the calcium-sensing receptor to extracellular calcium
Figure 1. Flow chart showing number of citations retrieved by database searching, and the trials included in this review.
Palmer SC, Nistor I, Craig JC, Pellegrini F, et al. (2013) Cinacalcet in Patients with Chronic Kidney Disease: A Cumulative Meta-Analysis of Randomized Controlled Trials. PLoS Med 10(4): e1001436. doi:10.1371/journal.pmed.1001436http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001436
Parathyroidectomy• Severe hypercalcemia.• Progressive and debilitating hyperparathyroid bone disease as
defined by radiographic or histologic evaluation. • Pruritus that does not respond to medical or dialytic therapy. • Progressive extraskeletal calcification or calciphylaxis that is
usually associated with hyperphosphatemia that is refractory to oral phosphate binders. In this setting, PTH-induced release of phosphate from bone contributes to the persistent elevation in the serum phosphate concentration. Parathyroidectomy will tend to minimize further calcification by lowering the serum calcium and phosphate concentrations
• Otherwise unexplained symptomatic myopathy.• PTH should > 800