Author František Švára, MD
Abstract. Clinical practice guidelines have been extensively developed over the last 11 years. Despite  some differences in their form and content, the aim was to improve the health care quality by using easily applicable, understandable evidence based procedures. In treatment of patients with kidney disease. original guidelines were developed but as knowledge advanced and given the complexity of this field, the growing evidence and amount of data resources together with the effort  to provide worldwide usable clinical tool gave rise to a global initiative of relevant and useable guidelines.
Key words Chronic kidney disease • Mineral and bone disorder • Renal osteodystrophy

Authors   Margaret J. Blayney, MSt; Francesca Tentori, MD
Abstract The Dialysis Outcomes and Practice Patterns Study (DOPPS), an ongoing observational study of haemodialysis patient and practices outcomes in 12 countries, provides detailed data on chronic kidney disease mineral bone disorder and related outcomes. This paper describes international trends in serum phosphorus, calcium, and parathyroid hormone (PTH) levels over the past 10 years and reviews DOPPS findings on the relationship between mortality (all-cause and cardiovascular) and levels of serum phosphorus, calcium, PTH, and alkaline phosphatase. In addition, the DOPPS has shown how abnormal levels of these mineral metabolism indicators are associated with increased risk of certain clinical outcomes, including parathyroidectomies, fractures, and pruritus.
Key Words: chronic kidney disease, DOPPS, mineral bone disease, phosphorus, calcium, parathyroid hormone, alkaline phosphatas

Author  Prof Monique Elseviers
Abstract: Data of the European Practice Database (EPD) was used to investigate the use of phosphate binders in the European HD population.  A cross-sectional observation among five participating countries of the cycle 2 study revealed that most patients used phosphate binders and many of them used more than one agent.  Calcium-based products were most frequently used (55% of HD patients) followed by Sevelamer (37%).  Distribution of the kind of phosphate binders used, varied widely between countries.  Renal dietitians advised regularly on therapy adjustment for calcium/phosphorus metabolism in one third of European countries and their involvement is increasing.
Keywords:Phosphate Binders, Medication use, European Practice Database, Therapy adjustment

Author Prof John Cunningham
Abstract  CKD- MBD signifies the complex pathophysiological interactions between calcium, phosphorus and regulatory hormones which are associated, sometimes causally, with impaired bone mineralization and increased fracture risk in patients with CKD  It also signifies a predisposition to vascular calcification, the emergence of which as a likely side effect of some of the current therapies poses a difficult problem for physicians aiming to treat patients with CKD. This complex disorder has seen several important advances in relation to understanding of the pathophysiology and, it is hoped, refinement of therapeutic approaches.
Key words.  CKD Vascular calcification. Bone mineralisation. Vitamin D Phosphorus. calcium. parathyroid hormone

Authors: Helen Eddington, Smeeta Sinha, Philip A Kalra
Abstract: Vascular calcification, which is associated with arterial stiffness, is now known to be an important predictor of cardiovascular and all-cause mortality in patients with renal disease. This calcification starts developing in the early stages of chronic kidney disease and is present in over 50% of patients at the time of dialysis commencement. Once calcification is present it progresses rapidly, though some medications have been shown to slow this progression. Vascular calcification and bone abnormalities are now both encompassed by the term of Chronic Kidney disease – mineral bone disorder and are thought to be part of the same disease process in CKD.
Vascular calcification and arterial stiffness have been extensively researched in the renal population and many factors are known to be associated with their presence and progression. This calcification is an important factor to be considered in the management of the renal patient but there are different methods available for its measurement. These details will be discussed further in this review along with evidence available for management of this important complication of renal disease
Key words: Bone Disease, Cardiovascular, Chronic Kidney Disease, Haemodialysis

Authors Smeeta Sinha, Helen Eddington & Philip Kalra
Abstract Patients with chronic kidney disease have increased cardiovascular mortality from a combination of increased atherosclerotic disease and increased prevalence of vascular calcification. Previously vascular calcification was thought to be a passive process which involved the deposition of calcium and phosphate into the vessel wall. However, recent studies have shown that vascular calcification is a highly regulated, cell-mediated process with similarities to bone formation, in that it is associated with expression of bone-related proteins, such as type I collagen and alkaline phosphatase. The use of animal and in vitro models of vascular calcification has shown that a multitude of factors including phosphate, matrix Gla protein and fetuin are involved in regulating vascular calcification. In addition certain factors appear to induce calcification whereas others inhibit the process. Despite these developments, it is still not fully known how vascular calcification is regulated and a treatment for vascular calcification remains to be found.  Ongoing research will hopefully elucidate these mechanisms and thereby produce targets for future therapeutic intervention. This review will highlight some of the scientific models of vascular calcification and how they have increased the understanding of this complex process.
Key Words: Vascular Calcification; Bone Disease; Cardiovascular; Basic Science; Chronic Kidney Disease

Authors: Jorge B. Cannata-Andía, Pablo Román-García, Natalia Carrillo-López
Abstract  This paper reviews the pathogenesis of hyperphosphataemia and its role in the regulation of parathyroid hormone synthesis and parathyroid cell proliferation in chronic kidney disease. The association between hyperphosphaemia and vascular calcification, and the interventions that can be used to control plasma phosphate are also discussed.
Key words  Hyperphosphataemia.  Parathyroid hormone synthesis. Vascular calcification. plasma phosphate.

Author Sylvie Dusilová Sulková
Abstract Vitamin D plays essential role in human physiology. The biological effect of vitamin D is gene control. VDR activation inhibits cell differentiation and proliferation and participates in the regulation of apoptosis (programmed cell death).
Vitamin D status is assessed according to serum 25-hydroxyvitamin D concentration. Low vitamin D status is associated with bone and mineral disturbances, this status is common, but underestimated.
Native vitamin D undergoes two-step hydroxylation  - 1.becoming biologically active, 2.metabolic conversion which depends on functional renal parenchyma. The parathyroid hyperactivity in advanced CKD represents approved indication for pharmacologic VDR activation. The effect of selective VDR activators (paricalcitol) in intestine is lower and is safer in terms of maintaining serum concentration of calcium and phosphate.
Studies demonstrated survival benefits of selective VDR activation in CKD patients. The possible cardioprotectivity, renoprotectivity and other benefits of selective VDR activators are intensively studied.
Key words: Vitamin D, vitamin D receptor, selective vitamin D receptor activation, chronic kidney disease, syndrome of vitamin D deficiency, paricalcitol, calcitriol

Authors J.Bover, N. Farré, E. Andrés, C. Canal, M. Olaya, M. Alonso, B. Quílez, J. Ballarín
Abstract  Chronic kidney disease (CKD) is associated with increased morbidity and mortality. Mineral metabolism disturbances appear to contribute to the high mortality rate. A CKD-mineral bone disorder (CKD-MBD) has recently been defined as a systemic disorder manifested by one or a combination of abnormalities in bone biopsy, laboratory parameters and/or vascular or other soft tissue calcifications. New available treatments have contributed to move from the former treatment paradigm of renal osteodystrophy to CKD-MBD management, beyond the mere control of PTH and trying to improve cardiovascular or survival outcomes. Thus, the recommended multidisciplinary approach among nurses, dietitians and clinicians, helping not only through dietary assessment but also through education, behaviour control and by increasing patient’s personal motivation, may have additional important benefits. This article will review the current therapeutic approach with phosphorus binders including the last developments, vitamin D derivatives and selective vitamin D receptor activators as well as the new calcimimetics, all used in the treatment of this systemic disease.
Keywords: Secondary hyperparathyroidism, chronic kidney disease, CKD, CK-MBD, vitamin D, paricalcitol, calcimimetics, phosphorus binders, sevelamer, lanthanum, vascular calcification

Alastair J. Hutchison MBChB, FRCP, MD
Abstract  Hyperphosphataemia is an inevitable consequence of end stage chronic kidney disease and is present in the majority of dialysis patients. Hyperphosphataemia is statistically associated with increased cardiovascular mortality among dialysis patients. Dietary restriction of phosphate and current dialysis modalities are not sufficiently effective to maintain serum phosphate levels within the recommended range so that the majority of dialysis patients require oral phosphate binders.  However, benefits of achieving the recommended range have yet to be demonstrated prospectively.
Unfortunately, conventional phosphate binders are not reliably effective and are associated with a range of limitations and side effects. Aluminium containing agents are highly efficient but no longer widely used because of well established and proven toxicity. Calcium based salts are inexpensive, effective and most widely used but there is now concern about their association with hypercalcaemia and vascular calcification. Sevelamer hydrochloride and lanthanum carbonate are non-aluminium, calcium-free phosphate binders. They are effective and reasonably well tolerated, but still do not control phosphate levels in all patients.  Patient education programmes have been shown to be a useful and effective method of improving achievement of serum phosphate targets.
Key words Bone Disease, Cardiovascular, Chronic Kidney Disease, Education, Treatment

Authors MK Sigrist PhD , A Levin PhD
Abstract.  Dietary management of hyperphosphatemia and therefore hyperparathyroidism have long been important elements in the clinical management CKD 4 and 5 patients with the primary objective of preventing renal osteodystrophy.   More recently the rationale for phosphate lowering advice has extended to its role in vascular damage and vascular calcification in this population at high risk of cardiovascular disease (USRDS 2002).  Phosphate itself has been identified as a novel cardiovascular risk factor in both CKD and in the general population (Block et al 2004, Tonelli et al 2005).  In addition, a growing body of literature suggests that higher serum phosphate (within the normal range) is a risk factor for progression of CKD to end stage (Voormolen et al 2007, Norris et al 2006, Schwarz et al 2006). In light of this, there could be sufficient evidence to support the use of phosphate lowering at earlier stages of CKD, perhaps even prior to serum phosphate level rising.  This review will discuss the potential benefits of early phosphate intervention, practical considerations of low phosphate diets and novel strategies for evaluating the effectiveness of phosphate lowering strategies in clinical practice.
Key words: cardiovascular risk, phosphate, vascular calcification, chronic kidney disease, diet.

Author Deepa Kariyawasam Senior Renal Dietitian BSc (Hons) RD
Abstract.  Hyperphosphataemia is a complication of renal failure which can lead to vascular calcification and hyperparathyroidism. Many factors influence phosphate levels, e.g. adherence to a low phosphate diet, adequate dialysis, hyperparathyroidism and concordance with phosphate binders. This article looks at the issues to consider and provides a dietitian’s perspective on phosphate management.
Key words  Bone Disease, Cardiovascular, Chronic Kidney Disease, Parathyroid, Treatment, Nutrition

Authors: R.Parham, S.Riley MD, A.Hutchinson,MD. Prof R.Horne.
Abstract. Phosphate binding medication (PBM) is an integral component of the treatment regimen for dialysis dependent Chronic Kidney Disease stage 5 (CKD 5). There is a need to explore patients’ satisfaction with information received about PBM. 221 patients with CKD 5 completed the Satisfaction with Information about Medicines Scale (SIMS); a validated measure of patients' satisfaction with various aspects of information provision. Widespread dissatisfaction with information received about PBM was evident. The highest levels of dissatisfaction related to information received about potential problems associated with PBM, particularly information received about whether PBM affects a patients sex life, what to do if side effects are experienced, and what the risks of side effects are. The findings suggest that CKD 5 patients are largely dissatisfied with the information that they have received about PBM. To facilitate informed choice, patients’ individual information requirements should be elicited and information tailored to meet these needs.
Key words:  Information needs, Patient satisfaction, Phosphate Binding Medication, Dialysis.

Elizabeth J Lindley, Ph.D
Abstract. The 2003 K/DOQI bone metabolism guidelines recommend a standard dialysate calcium concentration of 1.25 mmol/l. Studies of calcium balance that take ultrafiltration, as well as changes in ionised calcium, into account show that patients lose calcium when treated with this dialysate Ca. Compensation for negative calcium balance will usually be required in  patients with normal or high bone turnover, but may be impossible if the recommendations to restrict intake of calcium, and hold vitamin D therapy if serum phosphate is high, are followed.
A literature review suggests that conversion to 1.25 mmol/l dialysate Ca is beneficial in selected, but not all, patients. Conversion to higher dialysate Ca levels has been shown to improve control of calcium, phosphate and PTH, again in selected patients. Given the important role that dialysate calcium concentration plays in the management of renal bone disease, it should be prescribed on an individual basis like other medications.
Key words Bone Disease, Haemodialysis, Peritoneal Dialysis

Author Fernández Castillo MD
Introduction: Renal osteodystrophy is a serious problem for patients with Chronic Kidney Disease (CKD). Alterations in the bone mineral metabolism are an important cause of morbidity and mortality among haemodialysis patients. Bone mass diminution, together with fracture risk, is a frequent finding in these patients; this is explained by different factors, amongst which are those related to their anthropometric values.
Materials and Methods: Bone Mineral Density (BMD) was studied, T-score and Z-score measurements were taken in the neck of the femur, trochanter, intertrochanter, 1/3 of proximal femur, Ward´s triangle and L2, L3 and L4 vertebrae; body composition was also studied.  DXA densitometry was used  on 73 haemodialysis patients (40 men and 33 women).
Results:The group showed a very significant positive correlation between BMD, weight, height, BMI, fractures, dialysis time and intact PTH.
Conclusions:  CKD patients undergoing haemodialysis show a significant BMD reduction, which affects both lumbar spine and femur. Weight and height affect BMD and bone change, thus are important factors of prediction for fracture risk. Furthermore, BMI is the main determinant of BMD, a finding that is confirmed in this study and evidence from other authors (Negri A.L et al. 2005).
Key words: bone densitometry, body composition, osteoporosis, dialysis, fractures, hyperparathyroidism.

Authors. Claire Limrick, Renal Bone and Mineral Metabolism Nurse
Coral McNichols-Thomas, Anaemia Support Nurse
Abstract. Secondary hyperparathyroidism (SHPT) is one of the factors reported to have a negative impact on anaemia of chronic kidney disease (ACKD) and its treatment.  SHPT is one of the abnormalities resulting from altered bone mineral metabolism.  Five possible mechanisms have been proposed as to how SHPT impacts on anaemia in this paper.  Each of these mechanisms will be considered and the treatment options reviewed including the implications for erythropoietic stimulating agents (ESA) prescribing.  Anaemia and SHPT are both strongly predictive of complications and death from cardiovascular events in patients with chronic kidney disease.  Nursing care of this group of patients should therefore be holistic in order to ensure optimum management.  Ways in which we can practice to enhance quality of life and outcomes in this patient population will be discussed. 
Key words Anaemia, Bone Disease, Chronic Kidney Disease

Author Debbie Sutton Senior Community Dietitian.
NO abstract

Author Dr Michel Delaney 
NO abstract   The summary will be published as a reference list for practitioners