Kidney disease outcomes quality initiative guidelines for bone and mineral metabolism: emerging questions

Since their initial publication in 2003, the National Kidney Foundation Kidney Disease Outcomes Quality Initiative clinical practice guidelines for bone and mineral metabolism have transformed the clinical approach to the management of metabolic bone disease in both dialysis and nondialysis chronic kidney disease patients. These guidelines largely were based on expert opinion rather than evidence. In the past 5 years, with the publication of several randomized controlled trials, large observational studies, and smaller clinical series, significant progress has been made in our understanding of mineral metabolism, calcium and phosphorus management, and the use of activated vitamin D irrespective of parathyroid hormone level in chronic kidney disease. More recently, fibroblast growth factor-23 and serum alkaline phosphatase have been shown to predict mortality in dialysis patients, making these attractive markers to monitor. In the wake of this progress, the bone Kidney Disease Outcomes Quality Initiative guidelines will need to be revised. Here, we review some of the issues and controversies that likely will form the basis of these revised guidelines.