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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2010  |  Volume : 21  |  Issue : 1  |  Page : 93-101
Survey of attitudes of physicians toward the current evaluation and treatment of chronic kidney disease-mineral and bone disorder (CKD-MBD)


Saudi Center for Organ Transplantation, Riyadh, Saudi Arabia

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Date of Web Publication8-Jan-2010
 

   Abstract 

We aimed in this study to determine the opinion of the medical directors of dialysis centers in the Kingdom of Saudi Arabia (KSA) about the updates of strategies for evaluation and treatment of chronic kidney disease-mineral and bone Disorder (CKD-MBD). A questionnaire was sent to medical directors of 174 dialysis centers in the KSA between July and November 2009. The questionnaire was opinion based and comprised the prevalence of the CKD-MBD, strategies of therapy and indications of cinacalcet, a new therapy in the CKD patients. A total of 154 medical directors of the 174 (88.5%), who are the therapeutic decision-makers for 10100 (89%) dialysis patients, answered the questionnaire. There were 84 respondents (54%) who believed that the parathormone (PTH) blood levels initially increase at a glomerular filtration rate (GFR) < 30%. There were 80 (53%) respondents who believed that changes of phosphorus (PO4) and cal­cium (Ca) blood levels are initially observed at GFR < 30 mL/min. The majority of respondents, 115 (77%), 116 (80%), 95 (66%), and 134 (90%) currently have observed increased prevalence of vascular calcifications, adynamic bone disease, PTH > 500 pmol/L, and elevated Ca blood levels, respectively, only in the minority of advanced CKD. However, 88 (58%) respondents observed increased prevalence of elevated PO4 blood levels in the majority of new dialysis and advanced CKD patients. There were 137 (89%) respondents who believed from the current published evi­dence that CKD-MBD may result in increased morbidity (e.g. fractures) and mortality (e.g. cardiovascular) in advanced CKD and new dialysis patients. However, only 41 (27%) respondents follow the PTH levels in their patients every 2-3 months, while 81(53%) follow it every 6 months. There were 127 (83%), 129 (84%), 114 (75%) respondents who would start vitamin D (vit D) in dialysis and CKD patients for hypocalcemia, high PTH, and vit D 1,25 deficiency, respectively. However, only 51 (34%) respondents would start vit D therapy for vit D 25 deficiency. There were 98 (75%), 73 (57%) 74 (59%), and 88 (68%) respondents who claimed that they could achieve control of calcium levels alone, control of PO4 levels alone PTH levels alone , and all parameters of CKD-MBD in > 50% of their patients, respectively. There were 126 (82%) and 126 (82%) respondents who agreed to the indications of the cinacalcet that include refractory secondary hyperparathyroidism of dialysis patients to vit D and diet and phosphate binders together, and when surgical parathyroidectomy is contraindicated or fail in this population, res­pectively. However, 127 (83%) and 139 (91%) respondents disagreed to the indications that include indiscriminate prescription to all CKD patients or off label to some early CKD patients, respectively. We conclude that the medical directors of the active dialysis centers in Saudi Arabia are well aware of the morbidity and mortality caused by the CKD-MBD in addition to the indications of vit D and phosphate binders and cinacalcet therapy. However, the study suggests inadequate assessment of the prevalence, patterns of CKD-MBD, and results of intervention in the CKD patients such as treatment of vit D 25 deficiency, and knowledge of the availability of cinacalcet for the treatment of CKD-MBD. More local studies and guidelines are required to disseminate information about the current patterns of CKD-MBD for better approach to the management of this disorder in the kidney centers in this country.

How to cite this article:
Souqiyyeh MZ, Shaheen FA. Survey of attitudes of physicians toward the current evaluation and treatment of chronic kidney disease-mineral and bone disorder (CKD-MBD). Saudi J Kidney Dis Transpl 2010;21:93-101

How to cite this URL:
Souqiyyeh MZ, Shaheen FA. Survey of attitudes of physicians toward the current evaluation and treatment of chronic kidney disease-mineral and bone disorder (CKD-MBD). Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2020 Feb 25];21:93-101. Available from: http://www.sjkdt.org/text.asp?2010/21/1/93/58717

   Introduction Top


Surveys of opinion are a useful tool to commu­nicate current routine practices and approaches in the nephrology community concerning major issues related to patients' care. [1],[2],[3]

There are several improvements in the ma­nagement of mineral and bone disorder in the chronic kidney disease CKD-MBD patients since our first survey of opinion of the medical directors of the dialysis centers in the Kingdom of Saudi Arabia (KSA) in 2005. [4] For example, cinacalcet is now available in the KSA and is recognized by the panels who update the CKD­MBD international guidelines as a member of a new family of drugs that control the synthesis and secretion of the parathormone (PTH) by increasing the sensitivity of the calcium (Ca) receptors in the parathyroid glands in a unique mechanism than the other conventional approa­ches including vitamin D and phosphate bin­ders. [5],[6],[7],[8],[9],[10]

Guidelines of management of CKD-MBD in the KSA may be attainable by surveying the opinion of the medical directors of the dialysis centers about this subject.

The aim of this study is to survey the attitude of the medical directors of the dialysis centers in the KSA towards their approaches to the assessment and management of the CKD-MBD and compare them to the current international guidelines.


   Materials and Methods Top


A questionnaire was sent from the Saudi Center for Organ Transplantation, Riyadh, Saudi Arabia to medical directors of 174 dialysis centers in the KSA. This covered decision makers in 115 centers (67 %) in the Ministry of Health (MOH), 21 centers (12%) in the governmental, non­MOH sector and 38 centers (22 %) in private hospitals that care for a population of more than 11,300 chronic dialysis patients. The study was performed between July and November 2009. The questionnaire was intended to eva­luate the following aspects in the practice of physicians who manage CKD patients in the KSA:

  • The perception of the physicians about the mechanisms of CKD-MBD.
  • The perception of the physicians about the current prevalence of the CKD-MBD.
  • The current approaches of the physicians in the KSA to the assessment and therapy of the secondary hyperparathyroidism in the CKD patients.
  • The perception of the physicians about their success in controlling the different para­meters of the CKD-MBD.
  • The perception of the physicians in the KSA about the indications, dosing and mo­nitoring of cinacalcet in the control of the CKD-MBD.


We considered the best answers as those in accordance with the common denominator of the established international guidelines and the facts about the CKD-MBD. [11],[12],[13],[14]


   Statistical Methods Top


Data were entered in a Microsoft Excel file. However, the description of data and analysis were done using the statistical program SPSS. The valid percent of the answers was consi­dered according to the frequency of the answers to each corresponding question. Pearson Chi­Square 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


A total of 154 medical directors of the 174 (88.5%) dialysis centers answered the ques­tionnaire. This covered 10100 (89%) dialysis patients in the KSA. There were 111 (96.5%) respondents of 115 MOH centers, 16 of 21 (76.2%) governmental non-MOH centers, and 27 of 38 (71%) private centers.

[Table 1] shows the answers related to the pre­valence of CKD-MBD. There were 70 respon­dents (46%) who believed that the parathormone (PTH) blood levels increase at a glomerular filtration rate (GFR) close to 50 mL/min, while the rest believed the initial rise occurs at a GFR <30%. There were 80 (53%) respondents who believed that changes of phosphorus (PO4) and calcium (Ca) blood levels are observed at GFR < 30 mL/min, while 57 (38%) believed they occurred at GFR <50 mL/min, and 13 (9%) believed they occurred at GFR < 15 mL/min. The majority of respondents, 115 (77%), 116 (80%), 95 (66%), and 134 (90%) currently have observed increased prevalence of vascular cal­cifications, adynamic bone disease, PTH > 500 pmol/L, and elevated Ca blood levels, respec­tively, only in the minority of advanced CKD and new dialysis patients. However, 88 (58%) respondents observed in-creased prevalence of elevated PO4 blood levels in the majority of new dialysis and advanced CKD patients.

[Table 2] shows the preferences of the respon­dents of the different treatment strategies of the BD-MD in the CKD patients. There were 137 (89%) respondents who believed from the current published evidence that CKD-MBD may result in increased morbidity (e.g. fractures) and mortality (e.g. cardiovascular) in advanced CKD and new dialysis patients. However, only 41 (27%) respondents follow the PTH levels in their patients every 2-3 months, while 81 (53%) follow it every 6 months. There were 127 (83%), 129 (84%), 114 (75%) respondents who would start vitamin D (vit D) in dialysis and CKD patients for hypocalcemia, high PTH, and vit D 1,25 deficiency, respectively. However, only 51 (34%) respondents would start vit D therapy for vit D 25 deficiency, and the rest either disagreed to this strategy or had no idea about this indication for vit D. Only 56 (37%) respondents agreed with the current studies that showed no significant difference in the pre­valence of vascular calcifications in the CKD patients treated with calcium based and non­calcium based phosphate binders, and the rest either disagreed or did not have an idea about the subject. When they were asked about the results of treatment strategies of CKD-MBD according to the international guidelines, There were 98 (75%), 73 (57%) 74 (59%), and 88 (68%) respondents who claimed that they could achieve control of calcium levels alone, control of PO4 levels alone, PTH levels alone, and all parameters of CKD-MBD in > 50% of their patients, respectively.

[Table 3] shows the opinions of the participants about indications of cinacalcet, a new therapy for CKD-MBD. There were 97 (63%) who knew about the availability of cinacalcet and agreed to the indication of this drug for better control of PTH and minerals than vitamin D and phosphate binders, and 115 (76%) respon­dents who agreed that cinacalcet acts through increasing the sensitivity of the Ca receptors of the parathyroid glands to suppress the synthe­sis and secretion of PTH > 30% in 60% of the CKD patients with 30-180 mg once daily dose. Furthermore, 126 (82%) and 126 (82%) respon­dents agreed to the indications of the cinacalcet that include refractory secondary hyperpara­thyroidism of dialysis patients to vit D and diet and phosphate binders together, and when sur­gical parathyroidectomy is contraindicated or fail in this population, respectively. However, 127 (83%) and 139 (91%) respondents disagreed to the indications that include indiscriminate prescription to all CKD patients or off label to some early CKD patients, respectively.

There was no statistically significant diffe­rences among the respondents according to their affiliations to the non MOH or the private sector on any of the issues in the question­naire. However, the respondents of both sectors showed some differences in the answers with those in the MOH sector. The differences bet­ween the MOH and private sectors were in the questions 7, 9, and 11b that showed significantly lower percentages of MOH respondents who agreed positively with the statements in those questions (34% vs 37%, 50.9% vs 92 %, and 65% vs 85%), respectively, with P values 0.02, 0.004, and 0.046, respectively. In addition, the MOH respondents showed a significantly less percentage of respondents who agreed positively with the statements in questions 3a, 5, 9, 10 and 11b (84%vs 53%, 25%vs 50%, 50%vs 100%, 69%vs 100%, 79%vs 100%, and 65%vs 93%, respectively) with P values of 0.01, 0.01, 0.001, 0.037, 0.04, 0.02, respectively.


   Discussion Top


The results of our study suggest adequate per­ception of the respondents to the importance of CKD-MBD in causing significant morbidity and mortality in the advance CKD and new dialysis patients, and to the indications of the cinacalcet. However, the results showed inade­quate perception of the physicians about the mechanisms of CKD-MBD, the current preva­lence of the CKD-MBD, the assessment and therapy of the secondary hyperparathyroidism in the CKD patients, and the success in con­trolling the different parameters of the CKD­MBD in the CKD patients.

The mechanism of CKD-MBD include the initial decrease of vit D blood levels at an early stage of CKD accompanied by a trade off phenomenon with increased PTH blood levels; all occur before the decrease of GFR < 30 mL/min. [15],[16] Later, with further decrease of GFR< 30 mL/min, the elevated Po4 and decrease of Ca levels are detected in the majority of the CKD patients. [17] Most of the respondents in our study did not vote properly to these facts of the CKD-MBD, which may reflect inadequate a­wareness of the dimensions of this disorder in the CKD patients.

The current prevalence of the CKD-MBD is reported to remain elevated with a change in pattern from the mixed hyperparathyroidism and osteomalacia to the adynamic bone disease with increased vascular calcifications. [11],[12],[13],[14],[17],[18],[19],[20],[21] The respondents in our study observed the change only in the minority of the CKD pa­tients in contrast with the increased prevalence observed by others, [17],[18],[19],[20],[21] but still notice conti­nuing increased prevalence of elevated PO4 blood levels in this population. The definition of prevalence require good assessment of the disease including X-rays, bone biopsies, and chemical and hormonal parameters checked pe­riodically and compare the results with current therapy in the dialysis centers according to the local and international guidelines. [11],[12],[13],[14] The mere follow-up of chemical investigations is usually not sufficient for the evaluation of the CKD­MBD in the CKD patients.

The majority of the respondents in our study agreed, comparably with previous studies, [20],[21],[22],[23],[24],[25] to the importance of the CKD-MBD in causing significant morbidity (e.g. fractures) and morta­lity (e.g. cardiovascular) in advanced CKD pa­tients. However, the approach of our respon­dents to evaluate the CKD-MBD is still not adequately aggressive or accurate. For example, the assessment and therapy of the secondary hyperparathyroidism in the CKD patients in­clude determination of the PTH levels, an im­portant parameter for CKD-MBD, [26] which should be performed every 2-3 months in the advanced CKD and dialysis patients. The majo­rity of the respondents still obtain PTH blood levels on their patients at longer intervals than recommended in the guidelines. [11],[12],[13],[14] Another example is the vit D 25 deficiency that can be managed easily by supplementation in CKD patients; it was not recognized by the majority of the respondents in our study as an indication for therapy in contrast with what is reported in literature. [11],[12],[13],[14],[27],[28],[29],[30] However, they voted appro­priately to the other indications of vit D the­rapy. [11],[12],[13],[14],[31],[32],[33],[34],[35],[36],[37]

What was intriguing in the answers of our respondents manifested in the estimations of the success rates in controlling the different parameters of the CKD-MBD. According to the international registries and other cohort studies, [20],[38],[39],[40],[41],[42],[43] the success rates to achieve con­trol of Ca, PO4, and PTH compatible with the international guidelines was < 50% when each parameter was considered alone, and around 20% when all parameters were considered to­gether in the CKD population. Our respon­dents voted to 90% control of the all the para­meters, which did not reconcile with the inter­national figures and their voting in this study to the increased prevalence of PO4 levels and the low frequency of determining the PTH levels in their patients.

There are some controversial issues such as the worsening of vascular and soft tissue calcifications with the use of calcium-based phos­phate binders and their improvements when the non-calcium based binders are used instead. Only a minority of the respondents in our study concurred that the choice of the phosphate binder did not reflect in a difference in the status of the vascular calcifications, which is compatible with the general view of the guide­lines and other studies in the literature. [11],[12],[13],[14],[44],[45],[46],[47]

The questions about the indications, dosing and monitoring of cinacalcet were included in our study as an example of a new therapy for the CKD-MBD. [48],[49],[50],[51],[52],[53],[54],[55],[56] The indications of cinacal­ cet are currently restricted to the dialysis popu­lation because of the concern about the possi­ble increase soft tissue calcifications in the predialysis CKD patients. [11],[12],[13],[14] Our respondents mostly agreed to this notion, however, many of them did not know about the availability of the drug in the KSA and the current dosing schedule.

The comparison between the three sectors of health in the KSA revealed some statistically significant differences among them, but the issues were minor, which allows us to consider the overall differences as insignificant.

The limitations of our study stem from the design of the questionnaire, which should be more elaborative. However, the compliance of the respondents with answering the questions dictated restriction of the number of the ques­tions. Highlighting the problems with the cur­rent approach to assessment and therapy of the CKD-MBD is a good aim of our survey, which we believe has been served.

We conclude that the medical directors of the active dialysis centers in the KSA are well aware of the morbidity and mortality caused by the CKD-MBD in addition to the indications of vit D, phosphate binders, and cinacalcet the­rapy. However, the study suggests inadequate assessment of the prevalence, patterns of CKD­MBD, and results of intervention in the CKD patients such as treatment of vit D 25 defi­ciency, and knowledge of the availability of cinacalcet for the treatment of CKD-MBD. More local studies and guidelines are required to disseminate information about the current patterns of CKD-MBD for better approach to the management of this disorder in the kidney centers in this country.


   Acknowledgement Top


We would like to thank Amgen Pharmaceu­ticals in Saudi Arabia for their grant that made this study possible.

 
   References Top

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52.de Francisco AL, Izquierdo M, Cunningham J, et al. Calcium-mediated parathyroid hormone release changes in patients treated with the calcimimetic agent cinacalcet. Nephrol Dial Transplant 2008;23:2895-901.  Back to cited text no. 52  [PUBMED]  [FULLTEXT]  
53.Lomonte C, Vernaglione L, Chimienti D, et al. Does vitamin D receptor and calcium receptor activation therapy play a role in the histopatho­logic alterations of parathyroid glands in refractory uremic hyperparathyroidism? Clin J Am Soc Nephrol 2008;3:794-9.  Back to cited text no. 53  [PUBMED]  [FULLTEXT]  
54.Fukagawa M, Yumita S, Akizawa T, et al. Cinacalcet (KRN1493) effectively decreases the serum intact PTH level with favorable control of the serum phosphorus and calcium levels in Japanese dialysis patients. Nephrol Dial Transplant 2008;23:328-35.  Back to cited text no. 54  [PUBMED]  [FULLTEXT]  
55.Block GA, Zeig S, Sugihara J, et al. Combined therapy with cinacalcet and low doses of vitamin D sterols in patients with moderate to severe secondary hyperparathyroidism. Nephrol Dial Transplant 2008; 23:2311-8.  Back to cited text no. 55  [PUBMED]  [FULLTEXT]  
56.Chonchol M, Locatelli F, Abboud HE, et al. A randomized, double-blind, placebo-controlled study to assess the efficacy and safety of cina­calcet HCl in participants with CKD not receiving dialysis. Am J Kidney Dis 2009; 53: 197-207.  Back to cited text no. 56  [PUBMED]  [FULLTEXT]  

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Correspondence Address:
Muhammad Ziad Souqiyyeh
The Saudi Center for Organ Transplantation, P.O. Box 27049, Riyadh 11417
Saudi Arabia
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PMID: 20061700

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    Abstract
    Introduction
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    Statistical Methods
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    Article Tables
 

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