BAB I

PENDAHULUAN
Mineral and bone disorder related to chronic kidney disease (CKD-MBD) affects almost all
patients with advanced kidney failure. It is characterized by abnormalities in biochemical
markers of mineral metabolism, impaired bone strength and accelerated soft tissue
and vascular calcifications [Gal-Moscovici and Sprague 2007]. Alterations in bone
metabolism cause bone loss; patients with CKD are, thus, burdened by an increased risk
of fractures. ( RENAL OSTEODISTROFI 4 PENTING BGT)
The kidney plays a vital role in the metabolism of minerals and bone health. It is not only the
target organ of several regulating hormones such as parathormon (PTH) and fibroblast growth
factor-23 (FGF-23), but it is also the main organ that activates vitamin D [1]. Thus, the abnormal
mineral metabolism occurs in chronic kidney diseases (CKD) and sequentially affects the bone
health. Recently it is renamed chronic kidney disease-mineral and bone disorder (CKD-MBD) as
a systemic syndrome (Figure 1) and is called renal osteodystrophy (ROD) (Table 1) if the disease
is
limited to the bone [2]
KDIGO differentiation between CKD-MBD and ROD in CKD MBD is a Systemic disorder of
bone and mineral metabolism manifested by Abnormalities of Calcium, phosphorus,
parathormone and vitamin D, Abnormalities in bone mineralization and volume, Vascular or
other soft tissue and vascular calcification. ROD: confined only to CKD bone disease with
Disturbance of bone morphology, Abnormal skeletal component by bone biopsy
histomorphometry. (RENAL OSTEO 6)
Renal osteodystrophy is a component of the mineral and bone disorders related to
CKD (CKD–MBD) and it is the term used to describe the spectrum of abnormalities in
bone morphology that develops in patients with CKD [4]. Skeletal abnormalities occur
in almost the total of stage 5 CKD patients. Aside from the greater risk of bone frac
ture within this patient group compared to general population [46], bone abnormalities
also have signifificant consequences over mortality and cardiovascular disease [34]. The
gold standard for the evaluation and diagnosis of renal osteodystrophy is bone biopsy.
An expanded classifification based on parameters of bone turnover, mineralization, and
volume (TMV system) is recommended to be used to assess bone pathology [4]. The TMV
system classififies renal osteodystrophy as: osteitis fifibrosa or advanced hyperparathyroid-
related bone disease, which is characterized by high bone turnover due to SHPT; adynamic
bone disease, which represents the major bone disease in peritoneal and hemodialysis
patients and is characterized by low bone turnover due to excessive suppression of PTH
with normal mineralization; osteomalacia, which is characterized by low turnover with
abnormal mineralization, where the bone volume may be low to medium, depending on
the severity and duration of the process, and it is commonly due to aluminum toxicity in
bone at a time when aluminum-based phosphate binders were used; and mixed uremic
osteodystrophy, which is characterized by abnormal mineralization with either high or low
bone turnover (RENAL OSTEODISTROFI 3)
Renal osteodystrophy (ROD) is the bone abnormalities component of CKD-MBD which
increases
the fracture risk in patients with CKD [4]. Renal osteodystrophy is a complex disorder of bone
density
and quality and is a form of osteoporosis. Therefore, the spectrum of CKD-MBD includes
osteoporosis, but involves other complex abnormalities as well. Adynamic bone disease is a form
of CKD-MBD characterized by low bone turnover and low bone formation [7]. Management
strategies for CKD-MBD are summarized in Table 3 [8, 10, 11]. Bone histomorphometry in
renal osteodystrophy is classified based on bone turnover, bone mineralization, and bone volume
[TMV classification] (Figure 1, Figure 2, Table 4) [7]. The last update of the Kidney Disease
Improving Global Outcome (KDIGO) CKD-MBD guidelines published in 2017 recommended
measurements of BMD to assess fracture risk [12]. It suggests measure-ment of BMD via DXA
in patients with stages 3-5 CKD and those on renal replacement therapy if they have risk factors
for osteoporosis or evidence of CKD MBD provided that outcome of the testing will affect
treatment decisions. This recent recommenddation was based on longitudinal studies
demonstrating the validity of T scores in patients with and without CKD

Figure 1. Schematic representation of TMV (bone turnover, mineralization, volume)

classification for bone
histomorphometry in renal osteodystrophy