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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2006  |  Volume : 17  |  Issue : 1  |  Page : 10-18
Attitude of Physicians towards the Management of Bone Disease in Hemodialysis Patients: A Questionnaire Based Survey


Saudi Center for Organ Transplantation, Riyadh, Saudi Arabia

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   Abstract 

This study is aimed at evaluating the attitude of physicians in dialysis centers in the Kingdom of Saudi Arabia (KSA) towards the management of bone disease. We sent a questionnaire to 168 physicians who jointly cared for 7214 chronic hemodialysis (HD) patients. A total of 134 physicians (79.8%) answered the questionnaire from 134 dialysis centers (91.7%) that cumulatively catered to 7030 dialysis patients (97.6%). Of them, 71 (53.4%) had a protocol for management of bone disease at their centers, while 87 (67.4%) believed that the current results of management of bone disease were satisfactory. About 84.2% and 82.7% of the physicians checked serum calcium and phosphorus levels respectively monthly, while only 24.6% would check parathormone (PTH) once every three months; 32.8% did not have this latter test available in their centers. Bone x-rays of the hands and clavicles were being performed once every year by 47.4%, while 38.4% would perform the x-rays as indicated by the clinical status. Therapy would be aimed to achieve mid-normal calcium and phosphorus levels by 64.9% and 56.8 % of the respondents respectively, while only 29.3% would try to achieve three times the normal level of the PTH. Only 43.3% of the respondents believed that sevelamer would be a safer phosphate binder than calcium or metal based one. Almost all the respondents used vitamin D, mostly by daily oral administration. Fifty-nine respondents (44.4%) believed that sevelamer plus vitamin D was better to control PTH than calcium-based phosphate binder plus vitamin D, while 51 (38.3%) had no idea about this issue. There were 57 respondents (42.5%) who believed that high intake of calcium would increase the risk of vascular and metastatic calcifications without hypercalcemia, while 43 (32.1%) had no idea. There were a significantly lower percentage of MOH centers having a protocol for management of bone disease in the dialysis patients. Also, there was a higher percentage of non-availability of PTH assay, lower tendency of the physicians to target low normal level of phosphorus and higher percentage to target normal levels of PTH in MOH centers. In addition, MOH physicians had significantly lesser tendency to consider sevelamer the best phosphate binder for the dialysis patients. Our study suggests that the current practices concerning the management of bone disease in dialysis centers in the KSA require refinement and a protocol to guide the management is required.

Keywords: Bone, PTH, Calcium, Phosphorus, Chronic renal failure, Survey, Saudi Arabia.

How to cite this article:
Souqiyyeh MZ, Shaheen FA. Attitude of Physicians towards the Management of Bone Disease in Hemodialysis Patients: A Questionnaire Based Survey. Saudi J Kidney Dis Transpl 2006;17:10-8

How to cite this URL:
Souqiyyeh MZ, Shaheen FA. Attitude of Physicians towards the Management of Bone Disease in Hemodialysis Patients: A Questionnaire Based Survey. Saudi J Kidney Dis Transpl [serial online] 2006 [cited 2020 Jun 3];17:10-8. Available from: http://www.sjkdt.org/text.asp?2006/17/1/10/32438

   Introduction Top


Survey of the attitude of physicians in the dialysis units towards their practices, are one of the tools to evaluate the quality of care provided to the patients on regular dialysis.[1],[2],[3]

Management of bone disease in patients on maintenance hemodialysis (HD) has been well outlined in the guidelines laid down by the Kidney and Dialysis Outcome Quality Initiative (K-DOQI) in 2003.[4] The goals and means of therapy of this compli­cation are defined according to the best evidence available from the medical literature. In addition, there is new understanding in the past few years of the mechanisms of the development of metastatic calcification in the vascular and soft tissues.[4],[5],[6] Accordingly, the management of the bone disease in patients with chronic renal failure (CRF) may experience even more changes in means and the goals in the near future.


   Aim of the Study Top


We attempted in this study to evaluate the attitude of the physicians working in the dialysis centers in the Kingdom of Saudi Arabia (KSA) towards the treatment of the bone disease. This included the following: laboratory evaluation of bone disease and metastatic calcification, the need for a protocol for the management of this complication, the preferences for the best approach to the management and the current understanding of treatment with phosphate binders and vitamin D. Additionally, we explored the current beliefs about metastatic calcification in the dialysis patients.


   Materials and Methods Top


We sent a questionnaire to 168 physicians; the heads of the 146 active dialysis centers in the KSA and 22 other consultants working in these units. This covered decision makers in 110 centers in Ministry of Health (MOH) (75.3%), 14 (9.5%) centers in governmental, non-MOH sector and 22 centers (15.2%) in the private sector, together catering to a population of more than 7214 chronic HD patients. The questionnaire was mailed to the targeted physicians during April 2005 and responses were received at the Saudi Center for Organ Transplantation (SCOT) during May-June 2005.

The questionnaire was intended to evaluate the following categories:

a) The physicians' perception of the significant factors involved in the pathogenesis of osteodystrophy and the need for a protocol for its management.

b) The methods (clinical and laboratory) that guide the physicians in their decisions about management of the factors involved in the process of osteodystrophy.

c) The physicians' preferences of the hypophosphatemic agents that are safe, efficient and cost effective.

d) The physicians' strategies towards monitoring of parameters during management of osteodystrophy.

e) The physicians' strategies towards the extent of control of the factors involved in the osteodystrophy.

Furthermore, we compared the responses according to the affiliation of the dialysis center (MOH, non-MOH, private) and adoption of a protocol for management of bone disease. We considered that the best answers were those in accordance with the common denominator of the K-DOQI guide­lines as under:

a) Bone disease and metastatic calcifi­cation in the HD patients is an important problem that needs

addressing by the attending physic­ians.[7]

b) There is a need to have a protocol for management of bone disease in the dialysis centers.[7]

c) The current results of management of bone disease are not satisfactory.[6],[8],[9],[10]

d) The frequency of checking serum calcium is at least every month.[11]

e) The frequency of checking serum phosphorus is at least every month.[11]

f) The frequency of checking parathyroid hormone is at least every 3 months.[11]

g) Checking the bone x-rays of hands and clavicles is according to the need for the clinical evaluation of the bone disease and not routinely performed.[12]

h) Bone biopsy should be performed as clinical status indicates.[13]

i) Other chemical or imaging tests such as bone Dual Energy X-ray Absorp­tiometry (DEXA) should be performed to evaluate bone disease as indicated. [13]

j) The target range of serum calcium considered optimal result of therapy should be mid to lower limit of normal.[14]

k) The target range of serum phosphorus considered optimal result of therapy should be mid normal. [15]

l) The target range of serum intact parathyroid hormone (PTH) consi­dered optimal result of therapy should be two to three times normal. [16]

m) Continued abnormality of bone minerals and PTH carry more risk of morbidity and mortality in a larger percentage of chronic dialysis patients than anemia or inefficient dialysis.[5]

n) The safest phosphate binder that should be used routinely in the dialysis patients is non-calcium non­-metal organic phosphate binder such as sevelamer.[17]

o) The currently maximum allowed daily dose of elemental calcium in the chronic dialysis patients is 1600 mg /day, which is not adequate to lower serum phosphorus.[17],[18]

p) Dialysis patients should be managed with vitamin D to suppress PTH unless there is a contraindication.[19]

q) It is a better strategy to administer vitamin D plus sevelamer than vitamin D plus calcium to suppress PTH.[17]

r) High intake of calcium increases the risk of vascular and metastatic calcifications without hypercalcemia in the dialysis patients.[17],[18],[20]

s) There is a role for the novel calcimi­metics in the management of bone disease in CRF patients but more experience is needed.[21]


   Statistical methods Top


Data was entered basically in a Microsoft Excel file; however the description of data and analysis was done by using the statistical program (SPSS).

Pearson Chi-Square test was used throughout the analysis to test the signi­ficance of differences between groups and sub-groups. Significance was set as P< 0.05.


   Results Top


There were 134 out of 168 physicians (79.8%) who answered the questionnaire from 134 dialysis centers (91.7%) that covered 7030 dialysis patients (97.6%) in the KSA. There were 105/110 respondents (95.4%) from the MOH centers, 14/17 from the non-MOH centers (82.3 %) and, 15/19 from the private centers (78.9%).

[Table - 1], shows the answers related to significance of the bone problems and their management in the dialysis population. There were 133 respondents (99.3%) who believed that bone disease and metastatic calcifi­cation are important problems in the HD patients, 71 (53.4%) had a protocol for management of bone disease at their centers, while 87 (67.4%) believed that the current results of management of bone disease were satisfactory at their centers.

[Table - 2] shows the frequency of laboratory check-up for evaluation of the bone disease in the dialysis patients. There were 112 respondents (84.2%) who would check calcium once a month and 110 (82.7%) who would check phosphorus once a month, while only 33 (24.6%) would check PTH once every three months and 44 (32.8%) did not have this latter test available in their centers. There were 63 respondents (47.4%) who would check the bone x-rays of the hands and clavicles once every year while 51 (38.4%) would perform the x-rays as indicated by the clinical status. There were 125 respondents (94.7%) who would never have a bone biopsy performed on HD patients, and 84 (64.6%) would not do any more tests besides those mentioned above to evaluate the bone disease in their dialysis patients.

[Table - 3] shows the physicians preferences for target ranges for the control of the minerals and parathyroid hormone in the dialysis patients, and effect on mortality. There were 87 respondents (64.9%) who would aim by therapy to achieve mid-normal serum calcium level and 75 (56.8 %) would target mid-normal serum phosphorus level, while only 36 (29.3%) would target three times normal level of PTH. There were 81 respondents (60.4%) who believed that continued abnormality of these parameters carry more risk of morbidity and mortality in a larger percentage of chronic dialysis patients than anemia or inefficient dialysis.

[Table - 4] shows the opinion about the regimens of bone disease therapy in the dialysis patients. There were only 58 respondents (43.3%) who believed that sevelamer would be a safer phosphate binder than calcium or metal based one, while the calcium based phosphate binder was still considered by 66 respondents (49.3%) as a safer binder. There were 68 respondents (51.5%) who considered a daily dose of 1600 mg of elemental calcium as a phosphate binder, the maximum recom­mended dose for the dialysis patients and 69 (52.3%) believed that this dose was adequate to control phosphorus in the dialysis patients. Almost all the respondents used vitamin D, mostly by daily oral admini­stration or a combination with intravenous route (59% vs. 41% respectively). There were 59 respondents (44.4%) who believed that sevelamer plus vitamin D was a better regimen to control PTH than calcium-based phosphate binder plus vitamin D, while 51 (38.3%) had no idea about this issue. There were 57 respondents (42.5%) who believed that high intake of calcium would increase the risk of vascular and metastatic calcifi­cations without hypercalcemia in the dialysis patients while 43 (32.1%) had no idea. There were 58 respondents (43.9%) who believed that the role of calcimimetics was well established in the management of bone disease in CRF patients, while 48 (36.4%) had no idea.

[Table - 5] shows the differences in the responses of the study participants according to their affiliation. In comparison to non­MOH and private dialysis centers, the MOH centers had the following features: a significantly lower percentage had a protocol for management of bone disease in the dialysis patients, a higher percentage of non-availability of PTH assay, a lower tendency of the physicians to target low normal level of phosphorus and a higher percentage to target normal levels of PTH in the dialysis patients. In addition, MOH physicians had significantly lesser tendency to consider sevelamer the best phosphate binder for the dialysis patients as well as lesser belief that high intake of calcium can increase the risk of vascular and metastatic calcification without hypercalcemia in the dialysis patients.


   Discussion Top


The current study attempted to detect the attitude of the physicians in charge of the HD centers in the KSA towards the manage­ment of bone disease and mineral meta­bolism in the chronic HD patients.

The results of this study show some good practices compatible with the general practice guidelines in the United States of America (USA).[5],[7],[11],[14],[15] The majority of the respondents concurred to the importance of bone disease and metastatic calcification in the dialysis patients, believed that calcium and phosphorus should be checked monthly, would target low to mid-normal serum levels of both minerals and considered the continued abnormalities of these parameters detrimental and contributing significantly to the worse outcome of the patients. The majority also used vitamin D besides the phosphate binders for a large percentage of the dialysis patients.

On the other hand, some responses might reflect uncertainty about some important aspects of the management of bone disease and mineral metabolism as addressed by the American guidelines. Almost half of the respondents admitted to not having a written protocol for the evaluation and management of the bone disease in the dialysis patients and two thirds considered the results of management satisfactory contrary to the current guidelines.[6],[7],[8],[9],[10] Only 25% of the respondents would check the PTH levels every three months and the remaining would check it at longer intervals or did not have it available at all. Only 29% of the respondents would target three times normal of the intact PTH serum levels, while the others would aim at tighter control of PTH in the dialysis patients. The role of PTH control in the management of mineral metabolism and bone disease cannot be over emphasized. The frequency of check up and maintaining the PTH level at triple normal are crucial to the better control of bone disease in the dialysis patients.[11],[16] The majority of the respondents would use x-rays routinely every year and the overwhelming majority would not use bone biopsy at all in the dialysis patients, and most of them would not use any other test, chemistry or scans, to evaluate bone disease in this population. X-rays and bone biopsy still have a role in the evaluation of the bone disease but should be done as indicated and not as routine tests.[12],[13] Furthermore, other tests such as the bone absorptiometry still have a role in the evaluation process.[13] Half of the respondents disagreed to sevelamer as the safest phosphate binder available. Sevelamer is gaining increased popularity as a safer phosphate binder than the calcium or metal based binders, as also lanthanum, which is newcomer to the field.[17] Almost half of the respondents believed that the maximum dose of elemental calcium as a phosphate binder and maximum intake of calcium would be around 3600 mg. In addition, the same percentage of the respondents believed that 1600 mg of elemental calcium was enough to control the phosphorus level in the CRF patients. Furthermore, less than half of the respon­dents believed that high intake of calcium would cause metastatic calcification without causing hypercalcemia. There is increasing evidence that there is no need to drive the calcium level to the high normal levels and that metastatic calcification increases with the high intake of calcium. Such hypothesis would sway many physicians away from use of calcium based phosphate binders since the needed dose to control phosphorus (> 3600 mg of elemental calcium daily) will exceed the recommended calcium intake (maximum 2000 mg elemental calcium daily).[17],[18] Less than half of the respondents believed the combination of sevelamer and vitamin D would be better than vitamin D and calcium based phosphate binders to control PTH in the dialysis patients. This also follows the hypothesis of the safest available phosphate binder we discussed above[17]. Less than half of the respondents believed that calcimimetics had an established role in the management of mineral metabolism and bone disease, while the others disagreed or had no idea about both issues. The role of the calcimimetics is still not clear in the management of the PTH and bone meta­bolism in the dialysis patients despite the promising results of the current studies.[21]

The comparisons in our study showed important observations. The great majority of the dialysis centers in the KSA belong to the MOH, which lagged behind the non­MOH centers in the knowledge of the guidelines related to the management of bone disease in the dialysis patients. The MOH dialysis centers tended not to have the PTH assay more than the other sectors and tended to have tighter control to normal instead of the three times normal. The respondents from the MOH centers were much less inclined than the other sectors to consider sevelamer the safest phosphate binder for the dialysis patients and to believe that high calcium intake would increase the risk of metastatic calcification without causing hypercalcemia. These results emphasize the need to address these issues and increase the awareness of the physicians in general guidelines for the whole KSA.

Finally, the use of protocol to guide the management by the staff in the HD centers imposes a significant positive impact on the practice. Half of the respondents in our study did not have such a protocol and mostly were from the MOH centers. This may call for the consideration of national guidelines that can be used as a basis for such protocols. We believe that it is SCOT, which should provide such guidelines for the KSA.


   Conclusion Top


We conclude that the current practices concerning the management of bone disease in the dialysis centers in the KSA require refinement in terms of the need to enforce the use of a protocol to guide evaluation and therapy in each dialysis unit. There is also a need to increase the awareness of physicians in those centers to the importance of the details of such treatment and the national guidelines in this regard.


   Acknowledgement Top


We would like to thank Genzyme pharma­ceuticals, Saudi Arabia for their grant that made this study possible

 
   References Top

1.Kane MT. The assessment of professional competence. Eval Health Prof 1992; 15:163-82.  Back to cited text no. 1  [PUBMED]  
2.Bender FH, Holley JL. Most nephro­logists are primary care providers for chronic dialysis patients: results of a national survey. Am J Kidney Dis 1996; 28(1):67-71.  Back to cited text no. 2    
3.Parry RG, Crowe A, Stevens JM, Mason JC, Roderick P. Referral of elderly patients with severe renal failure: questionnaire survey of physicians. BMJ 1996; 313 (7055):466.  Back to cited text no. 3    
4.National Kidney Foundation. K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis 2003;42(4 Suppl 3):S1-201.  Back to cited text no. 4    
5.Block GA, Klassen PS, Lazarus JM, Ofsthun N, Lowrie EG, Chertow GM. Mineral metabolism, mortality and morbidity in maintenance hemodialysis. J Am Soc Nephrol 2004; 15(8):2208-18.  Back to cited text no. 5    
6.Pisoni RL, Greenwood RN. Selected lessons learned from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Contrib Nephrol 2005; 149:58-68.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.National Kidney Foundation. K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis 2003; 42(4 Suppl 3):S 44.  Back to cited text no. 7    
8.US Renal Data System: USRDS 2003 Annual Report, Bethesda, MD, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases.  Back to cited text no. 8    
9.Held PJ, Pauly MV, Diamond L. Survival analysis of patients undergoing dialysis. JAMA 1987;257:645-50.  Back to cited text no. 9  [PUBMED]  
10.Young EW, Akiba T, Albert JM, et al. Magnitude and impact of abnormal mineral metabolism in hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 2004;44(5 Suppl 3):34-8.  Back to cited text no. 10    
11.National Kidney Foundation. K/DOQI clinical practice guidelines for bone meta­bolism and disease in chronic kidney disease. Am J Kidney Dis 2003;42(4 Suppl 3):S 52.  Back to cited text no. 11    
12.National Kidney Foundation. K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis 2003; 42(4 Suppl 3):S 58.  Back to cited text no. 12    
13.National Kidney Foundation. K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis 2003; 42(4 Suppl 3):S 57.  Back to cited text no. 13    
14.National Kidney Foundation. K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis 2003; 42(4 Suppl 3):S77.  Back to cited text no. 14    
15.National Kidney Foundation. K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis 2003; 42(4 Suppl 3):S 62.  Back to cited text no. 15    
16.National Kidney Foundation. K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis 2003; 42(4 Suppl 3):S 53.  Back to cited text no. 16    
17.National Kidney Foundation. K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis 2003; 42(4 Suppl 3):S 70-1.  Back to cited text no. 17    
18.National Kidney Foundation. K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis 2003; 42(4 Suppl 3):S 72-3.  Back to cited text no. 18    
19.National Kidney Foundation. K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis 2003; 42(4 Suppl 3):S 84-94.  Back to cited text no. 19    
20.Goodman WG, Goldin J, Kuizon BD, et al. Coronary-artery calcification in young adults with end-stage renal disease who are undergoing dialysis. N Engl J Med 2000; 342(20):1478-83.  Back to cited text no. 20    
21.Goodman WG. Calcimimetics: a remedy for all problems of excess parathyroid hormone activity in chronic kidney disease? Curr Opin Nephrol Hypertens 2005;14(4):355-60.  Back to cited text no. 21    

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Correspondence Address:
Muhammad Ziad Souqiyyeh
Saudi Center for Organ Transplantation, P.O. Box 27049, Riyadh, 11417
Saudi Arabia
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PMID: 17297531

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    Abstract
    Introduction
    Aim of the Study
    Materials and Me...
    Statistical methods
    Results
    Discussion
    Conclusion
    Acknowledgement
    References
    Article Tables
 

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