Difficulties in achieving the K/DOQI practice guidelines for bone and mineral metabolism

Hyperparathyroidism and alterations in bone and mineral metabolism are known to occur early in the course of chronic kidney disease (CKD). The etiology of these abnormalities is multifactorial. Phosphate retention and alterations in vitamin D metabolism play important roles. The recent practice guidelines from the National Kidney Foundation (NKF) have emphasized the need to approach these problems early in the course of CKD by measuring the levels of parathyroid hormone when glomerular filtration rates (GFRs) fall to less than 60 ml/min. If hyperparathyroidism is detected, then treatment must be undertaken to try to prevent its progression. Strict guidelines have been proposed for the management of these alterations in bone and mineral metabolism when kidney disease progresses to CKD stage V. Although the initial recommendations were often opinion based, evidence is accumulating to support these views. However, with our current therapeutic armamentarium, there is considerable difficulty in achieving these practice guidelines for calcium, phosphorus, calcium-phosphorus product, and parathyroid hormone on a sustained basis. New therapeutic agents are becoming available that will help with phosphorus control and control of hyperparathyroidism, and minimize the calcium load. Additional beneficial effects of vitamin D analogs are being uncovered and are being intensively investigated. It is hoped that with attention to these practice guidelines, control of the abnormalities of mineral metabolism will be improved and will lead to improved patient outcomes.