Renal Osteodystrophy

Aka: Renal Osteodystrophy, Chronic Kidney Disease related Bone Disease, Calcium and Phophorus Metabolism in Chronic Kidney Disease

advertisement

II. Indications

  1. Secondary Hyperparathyroidism in Chronic Kidney Disease Stage 5

III. Pathophysiology

  1. Primary: Decreased Glomerular Filtration Rate
    1. Hypocalcemia
      1. Decreased Vitamin D activity and deficiency with decreased Calcium absorption
    2. Hyperphosphatemia
      1. Phosphate retention
  2. Secondary Hyperparathyroidism
    1. Contrast with Primary Hyperparathyroidism (where Calcium is increased and phosphate low)
    2. Results in increased Osteoclast activity and increased bone turnover
  3. Ultimate bone impacts
    1. Oseteomalacia
    2. Osteitis Fibrosa Cystica

IV. Labs

  1. Serum Phosphate
  2. Serum Calcium
  3. Parathyroid Hormone
  4. 25-Hydroxyvitamin D
    1. Also increases PTH
    2. Replace if <30 ng/ml

V. Management: Parathyroid Hormone (PTH) target

  1. Target Parathyroid Hormone
    1. Stage 3: 35-70 pg/ml
    2. Stage 4: 70-110 pg/ml
    3. Stage 5: 150-300 pg/ml
  2. Initial Steps: Measures to suppress PTH Secretion
    1. Treat Hyperphosphatemia
    2. Give hormonally active Vitamin D (Calcitriol)
    3. Give Vitamin D Analogs (e.g. Zemplar)
  3. Persistent rise in PTH despite initial steps
    1. 25-OH-Vitamin D <30 ng/ml
      1. Replace with Ergocalciferol or Cholecalciferol
    2. 25-OH-Vitamin D >30 ng/ml: Give Cacitriol (if Calcium <9.5, Phosphorus <5.5, CaxPO4 <55)
      1. PTH 70-300 (ckd3) or 110-300 (ckd4) Calcitriol 0.25 mcg/day
      2. PTH 300-600: Calcitriol 0.5 to 1.0 mcg/day
      3. PTH 600-1000: Calcitriol 1 to 2 mcg/day
  4. Persistent rise despite above in Dialysis patients
    1. Calcimimetic: Cinacalcet (Sensipar) or Etelcalcetide (Parsabiv)
      1. Suppresses PTH by increasing Parathyroid Gland's Calcium-sensing Receptor Sensitivity
    2. Parathyroidectomy
      1. May be indicated in Hemodialysis patients with secondary Hyperparathyroidism
      2. Improves Hypercalcemia and Hyperphosphatemia
      3. Improves Bone Mineral Density
      4. Improves quality of life and decreases mortality
      5. Lau (2018) Clin J Am Soc Nephrol 13(6): 952-61 [PubMed]

VI. Management: Phosphate

  1. Serum Phosphorus Target
    1. Stage 3-4 CKD: 2.7 to 4.6 mg/dl
    2. Stage 5 CKD: 3.5 to 5.5 mg/dl
  2. Dietary phosphate restriction
    1. Limit phosphate to 800-1000 mg/day
    2. Avoid highly processed foods, fast foods and dark colas
    3. Indication
      1. PTH increased
      2. Phosphate levels >4.6 mg/dl
  3. Phosphate Binders (Hemodialysis patients)
    1. Calcium Carbonate (Tums, 40% elemental Calcium)
    2. Sevelamer carbonate (Renvela)
    3. Calcium Acetate (Phoslo, 21% elemental Calcium)
    4. Lanthanum Carbonate (Fosrenol)
  4. Avoid
    1. Calcium Citrate (citracal)
    2. Aluminum based binding agents (due to aluminum deposition in bone)

VII. Management: Calcium

  1. Serum Calcium and Serum Phosphate Target
    1. Keep Ca x PO4 <55
  2. Keep total Calcium 8.4 to 9.5
    1. Maximum Dietary Calcium 2000 mg/day (including Calcium based binders)
  3. Total Serum Calcium <8.4 (or PTH>55)
    1. Oral Calcium supplement
    2. Oral Vitamin D
    3. Calcitrol (Rocaltrol) 25 mcg every other day
  4. Total Serum Calcium >9.5 or PTH below goal
    1. Discontinue Calcium Supplementation
    2. Avoid Calcium-based Phosphate Binders
    3. Avoid Vitamin D

VIII. Complications

  1. Osteitis Fibrosa Cystica

IX. References

  1. Sell (2022) Am Fam Physician 105(3): 289-98 [PubMed]

Images: Related links to external sites (from Bing)

These images are a random sampling from a Bing search on the term "Renal Osteodystrophy." Click on the image (or right click) to open the source website in a new browser window. Search Bing for all related images

Related Studies

Ontology: Renal Osteodystrophy (C0035086)

Definition (MSHCZE) Postižení kostí vznikající při chronické renální insuficienci. V patogenezi se uplatňuje retence fosfátů při poklesu glomerulární filtrace s reaktivní hypokalcemií stimulující příštítná tělíska (sekundární hyperparatyreóza) a sníženou aktivací vitaminu D v ledvině (nedostatečná aktivita 1 alfa-hydroxylázy). Kostní onemocnění může mít charakter osteolytický či spíše osteomalatický, popř. smíšený. Klinický obraz bývá variabilní, bývají bolesti kostí, zad, svalová slabost, fraktury, deformity. V léčbě se uplatňuje snížení příjmu a resorpce fosfátů (např. hydroxidem hlinitým), zvýšený příjem kalcia a vyšší koncentrace kalcia v dialyzační tekutině, podávání aktivního vitaminu D (kalcitriolu). Závažný je vznik terciární hyperparatyreózy s hyperkalcemií a extraskeletálními kalcifikacemi (provádí se chirurgický výkon na příštítných tělískách). (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ )
Definition (MSH) Decalcification of bone or abnormal bone development due to chronic KIDNEY DISEASES, in which 1,25-DIHYDROXYVITAMIN D3 synthesis by the kidneys is impaired, leading to reduced negative feedback on PARATHYROID HORMONE. The resulting SECONDARY HYPERPARATHYROIDISM eventually leads to bone disorders.
Concepts Disease or Syndrome (T047)
MSH D012080
ICD9 588.0
ICD10 N25.0
SnomedCT 266617009, 197668007, 155858005, 16726004
English Osteodystrophies, Renal, Renal Osteodystrophies, Renal osteodystrophy NOS, renal osteodystrophy, renal osteodystrophy (diagnosis), Renal Osteodystrophy [Disease/Finding], osteodystrophy renal, renal bone disease, renal disease bone, Renal osteodystrophy NOS (disorder), Renal osteodystrophy, ROD - Renal osteodystrophy, Renal bone disease, Renal osteodystrophy (disorder), osteodystrophy; renal, renal; osteodystrophy, Renal Osteodystrophy, Osteodystrophy, Renal
Swedish Renal osteodystrofi
Japanese ｼﾞﾝｾｲｺﾂｲｴｲﾖｳｼｮｳ, 腎性くる病, 線維性骨炎, 腎性骨異栄養症, 腎性骨ジストロフィー, 骨異栄養症-腎性, 腎性骨形成異常症, 腎性骨症, 骨炎-線維性, 腎性骨形成異常, 腎性骨ジストロフィ, くる病-腎性, 骨ジストロフィー-腎性
Czech renální osteopatie, renální osteodystrofie, Renální osteodystrofie
Finnish Renaalinen osteodystrofia
Russian OSTEODISTROFIIA NEFROGENNAIA, OSTEOPATIIA NEFROGENNAIA, RAKHIT POCHECHNYI, ОСТЕОДИСТРОФИЯ НЕФРОГЕННАЯ, ОСТЕОПАТИЯ НЕФРОГЕННАЯ, РАХИТ ПОЧЕЧНЫЙ
Korean 콩팥(신장성) 뼈형성장애
Croatian BUBREŽNA OSTEODISTROFIJA
Polish Osteodystrofia nerkowa, Krzywica nerkowa
Hungarian Renalis osteodystrophia
Norwegian Renal osteodystrofi, Osteodystrofi, renal
Spanish osteodistrofia renal, SAI (trastorno), osteodistrofia renal, SAI, osteodistrofia renal (trastorno), osteodistrofia renal, Osteodistrofia renal, Osteodistrofia Renal
Dutch osteodystrofie; renaal, renaal; osteodystrofie, renale osteodystrofie, Dystrofie, renale osteo-, Osteodystrofie, renale, Renale osteodystrofie
Portuguese Osteodistrofia renal, Osteodistrofia Renal
German renale Osteodystrophie, Renale Osteodystrophie
French Ostéodystrophie rénale
Italian Osteodistrofia renale
Derived from the NIH UMLS (Unified Medical Language System)

Related Topics in Rheumatology

advertisement

2025 Family Practice Notebook, LLC. Terms | Privacy | About | Site Map | Newsletter | Blog

Footer Site Logo