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Diagnosis and Management of Mineral Metabolism in CKD

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Abstract

BACKGROUND

Chronic kidney disease (CKD) affects over 26 million Americans and is frequently complicated early in its course by disordered mineral metabolism and metabolic bone disease. Since CKD-related bone loss is often indistinguishable from osteoporosis by standard bone densitometry, many CKD patients may be inappropriately treated with bisphosphonates rather than CKD-specific therapies.

OBJECTIVE

To determine the prevalence of appropriate evaluation, diagnosis and management of metabolic bone disease among individuals with pre-dialysis CKD.

DESIGN AND PARTICIPANTS

Retrospective cohort study using electronic medical records of 69,215 ambulatory patients seen in the primary care clinics of an academic medical center.

MEASUREMENTS

Prevalence of CKD stages 3–4, frequency of diagnostic testing and treatment of metabolic bone disease.

MAIN RESULTS

Based on current diagnostic criteria and consistent with national data, CKD was present in 12% of the population. Bisphosphonates were used in 7.2% of patients, 20% of whom met criteria for CKD. Fewer than half of CKD patients underwent testing for parathyroid hormone (PTH) or 25-hydroxyvitamin D (25D) levels. Among those tested, vitamin D deficiency (25D <30 ng/ml) and secondary hyperparathyroidism (PTH >60 pg/ml) were present in 65% and 55%, respectively. Among patients with CKD, bisphosphonate use was nearly seven times as frequent as therapy with active vitamin D (12% vs. 1.7%, p < 0.0001), a primary treatment for CKD-associated metabolic bone disease.

CONCLUSIONS

Disordered mineral metabolism in CKD is common, under-diagnosed and under-treated. As a result, bisphosphonates may be prescribed inappropriately in patients with CKD.

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Acknowledgements

I.B. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

I.B. was involved in conception and design, acquisition of data, analysis and interpretation of data, drafting and critical revision of the manuscript, and statistical analysis. M.W. was involved in conception and design, analysis and interpretation of data, drafting and critical revision of the manuscript, and supervision. A.D. was involved in acquisition of data, critical revision of the manuscript, and technical support.

Support for the design and conduct of the study was provided by grants RO1DK076116 (MW), R01DK081374 (MW) and 1K23DK081677 (IB) from the National Institutes of Health and a Young Investigator Grant from the National Kidney Foundation (IB).

Conflict of interest statement

I.B. and A.D. have no conflicts of interest to declare. M.W. has received honoraria from Abbott, Genzyme, Shire, Amgen and Ineos, and research support from Shire.

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Authors and Affiliations

  1. Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Ishir Bhan MD, MPH

  2. Laboratory of Computer Science, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Ishir Bhan MD, MPH & Anil Dubey MD, MS

  3. Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA

    Myles Wolf MD, MMSc

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  1. Ishir Bhan MD, MPH
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  2. Anil Dubey MD, MS
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Correspondence to Ishir Bhan MD, MPH.

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Bhan, I., Dubey, A. & Wolf, M. Diagnosis and Management of Mineral Metabolism in CKD. J GEN INTERN MED 25, 710–716 (2010). https://doi.org/10.1007/s11606-010-1316-y

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  • DOI: https://doi.org/10.1007/s11606-010-1316-y

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