1 / 34

Calcium & phosphor disturbance CKD- MBD

Calcium & phosphor disturbance CKD- MBD. Dr. Atapour. Phosphor. P arathyroid hormone (PTH) 1,25(OH)2D ( calcitriol ) P hosphatonins , (fibroblast growth factor 23 (FGF23) T arget organs: Bone Kidney Intestine. GFR levels below 60 mL /min GFR below 30 mL /min.

dante
Download Presentation

Calcium & phosphor disturbance CKD- MBD

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Calcium & phosphor disturbanceCKD- MBD Dr. Atapour

  2. Phosphor • Parathyroid hormone (PTH) • 1,25(OH)2D (calcitriol) • Phosphatonins, (fibroblast growth factor 23 (FGF23) • Target organs: • Bone • Kidney • Intestine

  3. GFR levels below 60 mL/min • GFR below 30 mL/min. • Normal serum concentrations of calcium and phosphorus • Altered production of calcitriol, PTH, and FGF23.

  4. Eventually • Altered serum levels of calcium, phosphorus, PTH, calcitriol, and FGF23 • Disturbances in bone remodeling and mineralization or impaired linear growth in children (renal osteodystrophy) • Extraskeletal calcification in soft tissues and arteries. increased risk of fractures, cardiovascular disease, and mortality in CKD stage 4 to 5D patients. In 2006, the term chronic kidney disease–mineral bone disorder (CKD-MBD)

  5. Phosphorous Homeostasis • 60% and 70% of dietary Pi is absorbed by GI • Passive transport related to the concentration • Active transport stimulated by 1,25(OH)2D • The kidneys are responsible for maintaining Pi balance

  6. Factors that increase Pi excretion are • Increased plasma Pi concentration • PTH • FGF23

  7. Phosphorous Abnormalities in CKD • GFR

  8. Calcium • Serum calcium concentrations 8.5 to 10.5 mg/dL • The NKF K/DOQI guidelines recommend calcium-containing phosphate binders to 1500 mg of elemental calcium per day + 500 mg intake per day from diet=total intake of 2000 mg/day

  9. approximately 18% to 20% of calcium is absorbed the net intake is 400 mg/day from 2000 mg . • The excretion of calcium in stool and sweat = 150 to 250 mg/day • if patients have residual urine output, the excretion rate may increase by 50 to 100 mg/day • Thus, with400 mg net absorbed calcium, most patients will still be in positive calcium balance

  10. It is important to emphasize three points: • First, this 1500-mg maximum intake of elemental calcium from phosphate binders in the NKF K/DOQI guidelines is based on opinion because no recent formal metabolic balance studies are available to inform these decisions. • More recent international Kidney Disease Improving Global Outcomes (KDIGO) guidelines recommended that total calcium intake be restricted

  11. Second, in patients taking vitamin D calcitriol or its analogs, the intestinal absorption of calcium will be increased, and thus the maximum amount of calcium in the form of binders should probably be decreased.

  12. Third, in patients with low turnover bone disease, NKF K/DOQI and KDIGO guidelines do not recommend calcium binders with low turnover disease or very low PTH

  13. KDIGO: Diagnosis of CKD-MBDBiochemical Abnormalities

  14. Diagnosis of CKD-MBD: Biochemical Abnormalities In the initial CKD stagea, the recommendation is to monitor serum levels of: Phosphorus, Calcium, PTH, Alkaline phosphatase In CKD stages 3-5Db, frequency of monitoring serum calcium, phosphorus, and PTH should be based: On the presence and magnitude of abnormalities The rate of progression of CKD In childrenc, the suggestion is to begin monitoring in CKD stage 2 KDIGO. Kidney Int. 2009; 76 (Suppl 113):S1-S130

  15. Diagnosis of CKD-MBD: Biochemical Abnormalities In patients with CKD stages 3-5D, the suggestionsa are to: Measure 25(OH)D (calcidiol) levels Repeat testing on the basis of: Baseline values Therapeutic interventions Correct vitamin D deficiency and insufficiency in accordance to treatment strategies recommended for the general population KDIGO. Kidney Int. 2009; 76 (Suppl 113):S1-S130

  16. Evaluation of CKD-MBD: Biochemical Abnormalities Phosphate and Calcium

  17. Evaluation of CKD-MBD: Biochemical Abnormalities PTH

  18. Treatment of CKD-MBD: Phosphorus and Calcium

  19. Definition of “Normal” values “Normal” means within the above ranges. These are normal ranges for healthy individuals.

  20. Treatment of CKD-MBD:Phosphorus and Calcium In patients with CKD stages 3-5, the suggestions are to: Maintain serum P in the normal range a Maintain serum Ca in the normal range b Phosphate binders are suggested in the treatment of hyperphosphatemia c For choice of phosphate binder, it is reasonable to take into account c: CKD stage Presence of other components of CKD-MBD Concomitant therapies Side-effect profile a. 4.1.1 (2C); b. 4.1.2 (2D); c. 4.1.4 (not graded) KDIGO. Kidney Int. 2009; 76 (Suppl 113):S1-S130

  21. Treatment of CKD-MBD:Phosphorus and Calcium In patients with CKD stages 5D, the suggestion is to: Lower elevated P levels toward normal range (2C) Use a dialysate Ca concentration between 1.25 and 1.5 mmol/l (2.5 and 3.0 meq/L) (2D) Increase dialytic phosphate removal in the treatment of persistent hyperphosphatemia (2C) KDIGO. Kidney Int. 2009; 76 (Suppl 113):S1-S130

  22. Treatment of CKD-MBD: Phosphorus and Calcium In patients with CKD stages 3-5D and hyperphosphatemia, the recommendationa is to: Restrict calcium based phosphate binders in the presence of: Arterial calcification Adynamic bone disease Persistently low serum PTH levels Restrict the dose of calcium based phosphate binders and/or restrict the dose of calcitriol or vitamin D analog are suggestedb, in the presence of: Persistent or recurrent hypercalcemia KDIGO. Kidney Int. 2009; 76 (Suppl 113):S1-S130

  23. Patients In Whom it is Recommended Calcium Be Restricted Calcification Persistently Low PTH Hypercalcemia ABD 1,2,3 2,3,4 2 51% - 83% 57% 16% - 54% 5 – 40% CKD 3,4,6 20 –50 % HD 6 40 – 70% PD 5 1 Russo D, et al. Am J Neph 2007;27:152-158 2 Chertow GM, et al. Kidney Int. 2002;62:245-252 3 Block GA, et al. Kidney Int. 2005;68:1815-1824 4 Qunibi W, et al. AJKD. 2008 5 Andress D. Kidney Int. 2008;73:1345-1354 6 KDIGO. KI 2009; 76 (Suppl 113):S1-S130 Calcium Restriction

  24. Phosphate Binding Compounds KDIGO. Kid Int. 2009; 76 (Suppl 113):S1-S130

  25. KDOQI / KDIGO -treatment recommendations in 5D: • KDIGO Clinical Practice Guideline for CKD-MBD. Kidney Int 2009;76 (Suppl 113)

  26. PTH Levels

  27. Treatment of Abnormal PTH levels in CKD-MBD In patients with CKD stages 3-5 not on dialysis, the optimal PTH level is unknown In patients with levels of intact PTH (iPTH) above the upper normal limit of the assay, the suggestiona is to, first evaluate for: Hyperphosphatemia Hypocalcemia Vitamin D deficiency It is reasonable to correct these abnormalities with any or all of the followingb: Reducing dietary phosphate intake and administering phosphate binders, calcium supplements, and/or native vitamin D The suggestionc is to treat with calcitriol or vitamin D analogs if: Serum PTH is progressively rising and remains persistently above the upper limit of normal for the assay despite correction of modifiable factors KDIGO. KI 2009; 76 (Suppl 113):S1-S130

  28. KDOQI / KDIGO - PTH TARGETS • KDIGO Clinical Practice Guideline for CKD-MBD. Kidney Int 2009;76 (Suppl 113)

  29. KDIGO: Diagnosis of CKD-MBDVascular Calcification

  30. Diagnosis of CKD-MBD: Vascular Calcification In CKD stages 3-5D, the suggestionsa indicate that: It is reasonable to use alternatives to CT-based imaging to detect vascular calcifications, including: Lateral abdominal radiograph Echocardiogram Patients with known vascular/valvular calcifications can be considered at highest cardiovascular risk It is reasonable to use this information to guide the management of CKD–MBD KDIGO. Kidney Int. 2009; 76 (Suppl 113):S1-S130

  31. Diagnosis of CKD-MBD: Vascular Calcification In CKD stages 3-5D, the suggestionsa indicate that: It is reasonable to use alternatives to computed tomography-based imaging to detect the presence or absence of vascular calcification, including: Lateral abdominal radiograph Echocardiogram Patients with known vascular/valvular calcification can be considered at highest cardiovascular risk It is reasonable to use this information to guide the management of CKD–MBD a. 3.3.1 (2C) KDIGO. Kid Int. 2009; 76 (Suppl 113):S1-S130

  32. In Summary … KDIGO International Clinical Practice Guidelines Phosphorus Calcium PTH Evaluate PTH in context of hyperP, hypoCa, vitamin D deficiency Marked changes should trigger treatment changes Decrease cinacalcet in event of hypocalcemia Goal = Normal • Calcification represents the highest risk • Detect with x-ray/ultrasound • Restrict Calcium in • Hypercalcemia • Calcification • Low PTH • ADBD Treat the trends: Treat P and Ca to normal, PTH to Goal KDIGO. Kidney Int. 2009; 76 (Suppl 113):S1-S130

More Related