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CME

Chronic Kidney Disease - Mineral and Bone Disorder (CKD-MBD)

General Information

Description

  • systemic disorder of mineral and bone metabolism due to chronic kidney disease1

Also called

  • CKD-MBD

Definitions

  • chronic kidney disease - mineral and bone disorder1
    • systemic disorder of mineral and bone metabolism due to chronic kidney disease
    • characterized by any of the following
      • abnormalities of calcium, phosphorous, parathyroid hormone (PTH), fibroblast growth factor-23 (FGF-23) derangements, or vitamin D metabolism
      • abnormalities of bone turnover, mineralization, volume, linear growth, or strength
      • extra-osseous calcification including arterial, valvular, and myocardial calcifications
  • renal osteodystrophy - alteration in bone morphology in patients with chronic kidney disease1
    • mild - slight increase in bone turnover and normal mineralization
    • osteitis fibrosa - increased turnover and normal mineralization
    • mixed renal osteodystrophy - increased turnover and abnormal mineralization
    • osteomalacia - decreased bone turnover and abnormal mineralization
    • adynamic bone - decreased bone turnover and acellularity
  • types of hyperparathyroidism related to kidney disease
    • secondary hyperparathyroidism
      • up to 90% of untreated patients with chronic kidney disease reported to develop secondary hyperparathyroidism by the time dialysis started
      • reduced vitamin D levels and decreased production of 1,25-hydroxyvitamin D in the kidney combined with high phosphate levels cause PTH levels to increase and calcium levels to decrease
    • tertiary hyperparathyroidism
      • most commonly occurs after renal transplant and in dialysis patients with poorly controlled mineral bone metabolism
      • patients with secondary hyperparathyroidism before transplant continue to have high PTH levels after transplant
      • long term hypocalcemia thought to lead to hypertrophy of parathyroid tissue which then continues to overproduce PTH after calcium levels and kidney disease has resolved (though adenoma must be ruled out)
    • Reference - 19836494Surg Clin North Am 2009 Oct;89(5):1227full-text
    • see Primary hyperparathyroidism for additional information

References

General references used

  1. Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Work Group. KDIGO clinical practice guideline for the diagnosis, evaluation, prevention, and treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD). Kidney Int Suppl. 2009 Aug;(113):S1-130, focused 2017 update can be found in Kidney Int Suppl 2017 Jul;7(1):1, executive summary can be found in Kidney Int 2017 Jul;92(1):26
  2. Lewis R. Mineral and bone disorders in chronic kidney disease: new insights into mechanism and management. Ann Clin Biochem. 2012 Sep;49(Pt 5):432-40
  3. Moorthi RN, Moe SM. CKD-mineral and bone disorder: core curriculum 2011. Am J Kidney Dis. 2011 Dec;58(6):1022-36full-text

Recommendation grading systems used

  • Kidney Disease: Improving Global Outcomes (KDIGO) guideline recommendations
    • strength of recommendation
      • Level 1 ("we recommend") - most patients should receive recommended course of action
      • Level 2 ("we suggest") - different choices appropriate for different patients, based on patient's values and preferences
      • Not Graded - topic does not allow adequate application of evidence, not meant to be interpreted as being stronger recommendations than Level 1 or 2
    • quality of evidence
      • Grade A - high-quality evidence, true effect lies close to that of estimate of effect
      • Grade B - moderate-quality evidence, true effect likely to be close to estimate of effect, but there is possibility it is substantially different
      • Grade C - low-quality evidence, true effect may be substantially different from estimate of effect
      • Grade D - very low-quality evidence, estimate of effect very uncertain and often far from truth
  • National Kidney Foundation (NKF) strengths of recommendation
    • Grade A
      • strongly recommended that clinicians routinely follow guideline for eligible patients
      • strong evidence that practice improves health outcomes
    • Grade B
      • recommended that clinicians routinely follow guideline for eligible patients
      • moderately strong evidence that practice improves health outcomes
    • Clinical Practice Recommendations (Grade CPR)
      • consider following guideline for eligible patients
      • based on weak evidence or opinions of Work Group and reviewers that practice might improve health outcomes
    • Reference - NKF clinical practice guideline on chronic kidney disease in children and adolescents: evaluation, classification, and stratification (12777562Pediatrics 2003 Jun;111(6 Pt 1):1416)

Synthesized Recommendation Grading System for DynaMed Content

  • The DynaMed Team systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based Methodology).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed content, we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
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      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
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DynaMed Editorial Process

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Special acknowledgements

  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
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How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T908720, Chronic Kidney Disease - Mineral and Bone Disorder (CKD-MBD); [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T908720. Registration and login required.

Published by EBSCO Information Services. Copyright © 2020, EBSCO Information Services. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission.

EBSCO Information Services accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional.

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