CKD-

Mineral Bone Disease

• Basic physiology
• What is CKD-MDB
• Renal osteodystrophy
• Management
THE BASIC
PTH action:
- Increase calcium Secondary
reabsorption Hyperparathyroidism
- Increase phosphate
excretion
Hyperparathyroidism
Primary Secondary Tertiary

PTH
WHAT IS CKD-MBD
A systemic disorder of mineral and bone metabolism due to CKD
manifested by either one or a combination of the following:
• Abnormalities of calcium, phosphorus, parathyroid hormone (PTH),
or vitamin D metabolism.
• Abnormalities in bone turnover, mineralization, volume, linear
growth, or strength.
• Vascular or other soft-tissue calcification.
• Coronary artery
calcification
• Aortic
calcification
• Calciphylaxis
Begins as surface purple-coloured
Then the skin goes black in the centre This causes deep and often
mottling of the skin (retiform purpura
of star-shaped (stellate) extensive ulcers. Surgical intervention
) then bleeding occurs within the
purple lesions. may aggravate ulceration.
affected area.
Renal Osteodystrophy
• Renal osteodystrophy is defined as:
“ An alteration of bone morphology in patients with CKD”.
• It is one measure of the skeletal component of the systemic disorder
of CKD–MBD
• Consist of
1. Hyperparathyroid bone disease
(Osteitis Fibrosa)
2. Osteomalacia
3. Osteoporosis
4. Osteosclerosis
Management of CKD-MBD
 Treatment goal of CKD-MBD
• Remember! • Goals: 1. Phosphate
• PTH secretion is 1. Normalize binders
stimulated by: phosphate 2. Vitamin D
1. Low calcitriol 2. Normalize analogues
2. Low Calcium Calcium 3. Active Vitamin D
3. Reduce PTH agents
3. High phopsphate
4. Avoid 4. Cinacalcet
hypercalcemia
Lowering the phosphate
• Low phosphate diet • Phosphate binders
• Which to choose?
Hypocalcemic: Calcium
containing (Renacet, CaCO3)
Normocalcemic
Hypercalcemic: Non-calcium
containing binder (Sevelamer,
Lanthanum)
Replace Vitamin D
• Need to normalize phosphate level first (vitamin D increases gut
absorption of calcium and phosphate)
Colecalciferol
Ergocalciferol
Alfacalcidol

Active Vitamin D agent

Calcitriol
Suppress PTH
• Cinacalcet • Parathyroidectomy
 Calcimimetic • For patients with markedly elevated and
 Reduced PTH level by medical therapy- refractory PTH levels and
increasing calcium related signs and symptoms
sensing receptor • Indications that warrant parathyroidectomy in
sensitivity to the setting of elevated PTH values in the
extracellular calcium absence of another known etiology:
 Severe hypercalcemia
 Progressive and debilitating hyperparathyroid bone disease
 Refractory pruritus
Progressive extraskeletal calcification or calciphylaxis
 Otherwise unexplained myopathy