The 2017 KDIGO (Kidney Disease: Improving Global Outcomes) clinical practice guideline has been updated to include several recommendations for the diagnosis and treatment of chronic kidney disease (CKD)-mineral and bone disorder (MBD).
With the availability of new data from several randomized controlled trials and prospective cohort studies, the Work Group reexamined major issues from the previously published guidelines. Most of the 2009 recommendations were deemed applicable to current practice but 12 were modified based on new evidence and were structured using the GRADE system (a grade given for overall evidence and strength of the recommendation). Recommendations labeled as “Not graded” were based on general advice and were not part of systematic evidence review.
Some of the new recommendations related to the treatment of CKD-MBD targeting phosphate lowering and maintaining calcium include:
- In patients with CKD G3a–G5D, treatment of CKD-MBD should be based on serial assessments of phosphate, calcium, and parathyroid hormone (PTH) levels, considered together (Not graded)
- In patients with CKD G3a–G5D, decisions about phosphate-lowering treatment should be based on progressively or persistently elevated serum phosphate (Not graded)
- In adult patients with CKD G3a–G5D receiving phosphate-lowering treatment, the new guideline suggests restricting the dose of calcium-based phosphate binders (2B; suggested, moderate quality of evidence)
In children with CKD G3a–G5D, it is reasonable to base the choice of phosphate-lowering treatment on serum calcium levels (Not graded)
- In patients with CKD G5D requiring PTH-lowering therapy, calcimimetics, calcitriol, or vitamin D analogs, or a combination of calcimimetics with calcitriol or vitamin D analogs are suggested (2B; suggested, moderate quality of evidence)
In addition, for adult patients with CKD G3a–G5 not on dialysis, the new guideline indicates that calcitriol and vitamin D analogs should not be routinely used (2C; suggested, low quality of evidence) and should be reserved for use in patients with CKD G4–G5 with severe and progressive hyperparathyroidism (Not graded). “If initiated for severe and progressive [secondary hyperparathyroidism], calcitriol or vitamin D analogs should be started with low doses, independent of the initial PTH concentration, and then titrated based on the PTH response,” added the Work Group. “Hypercalcemia should be avoided.”
In children, calcitriol and vitamin D analogs may be considered to maintain serum calcium levels in the age-appropriate normal range (Not graded).
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