Managing bone parameters in dialysis patients: international guideline conflicts

The linkage between bone parameters (calcium, phosphate, parathyroid hormone) and cardiovascular death in dialysis patients has led to a major resurgence in interest in this area of nephrological practice. Two major groups have recently published extensive guidelines for clinical practice in this area--the National Kidney Foundation's Kidney Disease Outcomes and Quality Initiative from the United States, and the Caring for Australasians with Renal Impairment group from Australia and New Zealand. There are some important differences in their recommendations, which reflect variations in local clinical practice, reimbursement systems, and interpretation of the medical literature. Two areas of divergence are highlighted in this editorial--use of vitamin D and its analogs, and use of phosphate binders. Readers of guidelines such as these need to be careful to interpret such recommendations in the context of the realities of their local clinical practice and availability of therapies.