Management of bone disease in the dialysis patient

Bone disease arises in dialysis patients from either secondary hyperparathyroidism or aluminum accumulation. Certain clinical features and biochemical characteristics may help distinguish these disorders, although a bone biopsy is required for a definitive diagnosis. Hyperparathyroidism is managed by correcting serum phosphorus (dietary phosphate restriction plus phosphate binding agents), raising serum calcium (appropriate dialysate Ca, oral Ca supplements, and vitamin D sterols), and by the direct effect of vitamin D on the parathyroid glands. When these fail, parathyroidectomy is necessary. Aluminum-related bone disease is prevented by eliminating aluminum from dialysate and minimizing the intake of aluminum-containing gels. Preexisting aluminum intoxication can be treated with repeated infusions of desferrioxamine.