Strategies to manage low-bone turnover

Area of Science:

• Nephrology
• Bone Metabolism
• Vascular Health

Background:

• Paradigm shift from hypocalcemia to hypercalcemia and positive calcium balance as negative factors in dialysis patients.
• Calcium-based binders with vitamin D analogues can suppress parathyroid hormone (PTH), leading to adynamic bone disease (ABD) and increased vascular calcification (VC) risk.
• Increased prevalence of low-bone turnover diseases correlates with higher morbidity and mortality in dialysis populations.

Purpose of the Study:

• To present new evidence for treating adynamic bone disease (ABD) using non-calcium-based binders and low calcium dialysate.
• To evaluate the impact of these strategies on bone turnover, vascular calcification, and patient outcomes.
• To inform treatment strategies for preserving bone and vascular health in dialysis patients.

Main Methods:

• Review of evidence for non-calcium-based binders (sevelamer, lanthanum) in treating ABD.
• Analysis of studies using low calcium dialysate (1.25 mmol/l).
• Assessment of changes in parathyroid hormone (PTH) levels, bone turnover markers, bone formation, and vascular calcification progression.

Main Results:

• Sevelamer treatment reduced calcium levels, increased PTH, improved bone turnover markers, enhanced bone formation, and slowed VC progression.
• Lanthanum demonstrated beneficial effects on ABD histology in long-term studies, with ongoing debate on its long-term toxicity.
• Reducing calcium binders and using low calcium dialysate positively impacted markers of bone turnover.

Conclusions:

• Non-calcium-based binders and low calcium dialysate represent a new treatment strategy for adynamic bone disease (ABD) in dialysis patients.
• These approaches can improve bone turnover, reduce vascular calcification (VC), and potentially decrease morbidity and mortality.
• The use of non-calcium-based binders should be considered for high-risk patients with ABD and progressive vascular calcification.