The KDIGO 2017 CKD-MBD Guidelines have now been officially released and are available online:
The new guidelines were developed following a Controversies Conference in 2013 that identified several areas within the 2009 Guidelines which warranted potential revision or deletion, along with a series of topics to include in an updated systematic review.
Full-text PDFs are available at the links below. The Executive Summary by Ketteler et al. highlights the statements that have been updated and also summarises the rationale behind each change.
- Full CKD-MBD Guidelines (also via Kidney International)
- Executive Summary (also via Kidney International)
- Evidence Summaries
An overview of the main changes to the Guidelines regarding hyperphosphatemia and hyperparathyroidism is provided below.
Guideline changes regarding hyperphosphatemia
The 2017 CKD-MBD Update includes several changes relating to the management of elevated serum phosphate levels.
- In CKD Stage 3a-5D patients it is now suggested that phosphate levels are lowered towards the normal range in patients with hyperphosphatemia (Statement 4.1.2); there is an absence of data showing a benefit to CKD Stage 3a-4 patients of maintaining phosphate within the normal range, and some safety concerns
- Statement 4.1.5 suggests phosphate-lowering treatment (incorporating dietary change, binders, and dialysis) should only be initiated in the presence of progressive or persistent hyperphosphatemia; there is limited evidence for using phosphate-lowering treatments pre-emptively (emphasizing that early “preventive” treatment is not supported by data)
- Guidelines for phosphate binding treatment have also been updated, with dose-restriction of calcium-based binders now suggested with a higher degree of evidence (2B instead of 2C), rather than only in the presence of hypercalcemia, arterial calcification, adynamic bone disease and/or if serum PTH levels were persistently low (4.1.6)
- Reflecting a growing understanding of the varying bioavailability of phosphate from different food sources, a qualifying statement has also been added to the statement regarding restricting dietary phosphate, suggesting healthcare professionals consider animal, vegetable and additive phosphate sources in their dietary guidance to patients (4.1.8)
Guideline changes regarding secondary hyperparathyroidism
The most significant change regarding the management of elevated parathyroid hormone (PTH) is the recommended restriction of calcitriol and vitamin D analogs.
- Statement 4.2.2 suggests that these therapies “not be routinely used” in pre-dialysis CKD patients, and instead be reserved for CKD Stage 4-5 patients with severe and progressive hyperparathyroidism
- For dialysis patients requiring PTH-lowering therapy the Work Group has removed the suggested first-line treatment recommendations, emphasising the position of calcimimetics, calcitriol and vitamin D analogs as equal first choice options (Statement 4.2.4)
Other Guideline changes of note
The statements regarding the assessment of bone density were also significantly updated in the new Guidelines. Evidence from studies using DEXA showed that lower bone mineral density does predict incident fracture risk in patients with CKD Stage 3a-5D, and thus the suggestion has been amended to include bone mineral density assessment in those with CKD-MBD or risk for osteoporosis, if that assessment will impact on treatment decisions.
Another important change, or rather absence of change, is that referring to vascular calcification. Statements 3.3.1 and 3.3.2 have not been amended, meaning that the suggestion to use X-rays and echocardiograms to detect vascular/valvular calcification, and the use of this information to guide treatment of CKD-MBD, remain.