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Guideline bone disease

Richard Amerling1

  • 1Division of Nephrology and Hypertension, Beth Israel Medical Center, New York, N.Y., USA.

Blood Purification
|November 13, 2013
PubMed

Insights

Current dialysis guidelines for bone and mineral targets are flawed. They use an outdated parathyroid hormone (PTH) assay, potentially leading to adverse patient outcomes like adynamic bone disease.

Area of Science:

  • Nephrology
  • Mineral Metabolism
  • Bone Biology

Background:

  • Dialysis units exhibit poor compliance with KDOQI and KDIGO bone and mineral guideline targets.
  • Current guidelines rely heavily on observational data and an obsolete parathyroid hormone (PTH) assay.

Purpose of the Study:

  • To critique the current KDOQI and KDIGO guideline targets for bone and mineral management in dialysis patients.
  • To highlight the limitations of the intact PTH assay in assessing bone turnover and guiding treatment.

Main Methods:

  • Analysis of existing literature and guideline recommendations.
  • Critique of the biochemical assays used for PTH measurement.

Main Results:

  • The intact PTH assay inaccurately measures biologically active PTH (1-84 PTH) and its antagonist (7-84 PTH).
  • The assay cannot reliably differentiate between high and low bone turnover states within guideline target ranges.
  • Adherence to current targets is associated with increased adynamic bone disease, elevated calcium and phosphorus levels, and potentially worse patient outcomes.

Conclusions:

  • The current KDOQI and KDIGO bone and mineral guidelines require revision due to reliance on obsolete assays and observational data.
  • The limitations of the intact PTH assay may lead to suboptimal treatment strategies and adverse effects in dialysis patients.
  • Future guidelines should incorporate more accurate PTH assays and consider the biological activity of different PTH fragments.

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