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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM ASIA - AFRICA  
Year : 2015  |  Volume : 26  |  Issue : 4  |  Page : 823-826
CKD-MBD spectrum at the time of initiation of hemodialysis in Pakistani chronic kidney disease patients


Nephrology and Dialysis Unit, Department of Medicine, Pakistan Atomic Energy Commission (PAEC) General Hospital, Islamabad, Pakistan

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Date of Web Publication8-Jul-2015
 

   Abstract 

Chronic kidney disease (CKD) is associated with mineral and bone disorder (MBD), which results in significant morbidity and mortality. To determine the spectrum of CKD- MBD in the Pakistani population, we performed a retrospective review of the medical records of 63 native Pakistani CKD stage-5 patients at our unit at the initiation of hemodialysis from March 2009 to September 2011. The cohort included 28 males and 35 females, with an age range of 18- 87 years (mean age 51 years). We reviewed the serum parathormone (PTH) levels along with other serum biochemical markers according to the KDIGO 2009 guidelines. There were 25 (40%) patients who had PTH <150 pmol/L, 15 (22%) patients who had PTH from 150 to 300 pmol/L and 24 (38%) patients who had PTH >300 pmol/L. Subgroup analysis and follow-up of patients with initial PTH >300 pmol/L (n = 24) showed treatment response in nine patients (38%). We conclude that at initiation of hemodialysis, a significant number of patients had low PTH and a similar percentage of high PTH in our population states. Therefore, we recommend early assessment of renal bone disease spectrum to prevent morbidity and mortality associated with mineral bone disorder in CKD patients.

How to cite this article:
Hafeez E, Raza H, Khan RU, Anwar MA, Hussain T, Beg MA. CKD-MBD spectrum at the time of initiation of hemodialysis in Pakistani chronic kidney disease patients. Saudi J Kidney Dis Transpl 2015;26:823-6

How to cite this URL:
Hafeez E, Raza H, Khan RU, Anwar MA, Hussain T, Beg MA. CKD-MBD spectrum at the time of initiation of hemodialysis in Pakistani chronic kidney disease patients. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2019 Jul 21];26:823-6. Available from: http://www.sjkdt.org/text.asp?2015/26/4/823/160227

   Introduction Top


Chronic kidney disease (CKD) is associated with progressive adverse changes in bone and mineral metabolism. These changes start very early in CKD stage-2; however, symptoms usually appear later in stage-5 when patients are initiated on dialysis. [1],[2] Revised KDOQI and KDIGO (2006 and 2009) guidelines highlight the evaluation as well as management of mineral and bone disorders (MBD) associated with CKD. [3],[4],[5] According to the KDIGO 2009 guidelines, the new proposed term chronic kidney disease-mineral and bone disorder (CKDMBD) defines a broader syndrome encompassing mineral, bone and calcific cardiovascular abnormalities, which result in a significant morbidity and mortality of CKD patients. [4] Renal bone disease is one part of the CKD- MBD syndrome, and the spectrum varies from adynamic bone disease and osteomalacia to high-turnover osteodystrophic states. [1],[3],[6] Bone biopsy is the gold standard diagnostic test; however, this facility is not available everywhere and serum markers like parathormone (PTH) levels are used to document the disease spectrum. [4] Limited non-conclusive data on CKD-MBD spectrum are available from Pakistan.

We aimed in this retrospective study to document renal bone disease spectrum in native Pakistani CKD patients and to formulate local management guidelines.


   Materials and Methods Top


We retrospectively studied the medical records along with laboratory flow sheets for assessment of renal bone disease spectrum of 63 CKD stage-5 patients initiated on hemodialysis in our unit from March 2009 till September 2011. The study included 28 males and 35 females with an age range of 18-87 years (mean age 51 years). Renal bone disease spectrum analysis was performed on the basis of serum PTH levels along with other serum markers including serum calcium, phosphorous and Ca × PO product according to the KDIGO 2009 guidelines. We did not perform histopathological or radiological assessment of bone disease and vascular calcifications in our dialysis patients. Those CKD patients who were already started on maintenance hemodialysis before enrollment at our unit were excluded from the study. The patients with serum PTH >300 pmol/L were treated with per oral elemental calcium 500 mg as well as calcitriol 0.5-1.0 μg (1, 25 dihydroxy cholecalciferol) and titrated according to serum levels. Institutional Ethics Committee approval was obtained for this project


   Results Top


There were 25 (40%) patients who had PTH <150 pmol/L, 15 (22%) patients who had PTH from 150 to 300 pmol/L and 24 (38%) patients who had PTH >300 pmol/L. Subgroup analysis and follow-up of patients with initial PTH >300 pmol/L (n = 24) showed treatment response in nine patients (38%), with favorable results of treatment with calcium and calcitriol with reference to significant improvement in serum calcium as well as PTH levels [Table 1].
Table 1: Serum biochemical markers of high-turnover MBD (PTH >300) at initiation of dialysis and 6 months follow-up after treatment.

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   Discussion Top


There are four major types of bone disease in patients with CKD, including osteitis fibrosa cystica (high turn-over state), adynamic bone disease, osteomalacia and mixed renal osteodystrophy. [1],[2],[6] As many other diseases, the pattern of MBD has been changing over the last several decades. Currently, adynamic bone disease is the most commonly seen bone disorder, while osteitis fibrosa, osteomalacia and mixed disease are less frequently observed in several reports. [6],[7],[8],[9] The CKD-MBD changes start as early as CKD stage-2. However, symptoms usually appear later in the pre-dialysis stage or when patients are initiated on dialysis. [1],[2]

Recently, it has been observed that in patients with different geographic and ethnic origins, certain types of bone disease are more common than the others. Changsirikulchai et al in a study of 56 dialysis patients from Thailand (1996-1998), based on bone biopsy in combination with other serum markers analyses, revealed that adynamic bone disease, hyperparathyroidism, mixed osteodystrophy, mild lesion, osteomalacia and osteosclerosis were observed in approximately 41%, 29%, 20%, 5%, 4% and 2% of patients, respectively. [10] In another study of 98 dialysis patients in Europe (2003), bone biopsy revealed adynamic bone disease and osteitis fibrosa, each in approximately 20% of patients, with osteomalacia being observed only in a small number of patients while the remainder had mixed lesions. [11] Ferreira et al in a study of 119 hemodialysis patients from Portugal (2008), based on bone biopsies, confirmed that adynamic bone disease was the most frequent abnormality (59%) of CKD patients. [12] Our study results were comparable with the one conducted in Thailand favoring the geographic pattern of the disease prevalence and similarities in treatment options and dialysis prescriptions. In Pakistan, a substantial majority of patients with evolving renal diseases are managed by general physicians and referral to a nephrologist is usually done very late in the course of the disease. It is observed in Pakistan that at the pre-dialysis phase of CKD, because of the lack of a proper healthcare system, the majority of patients are usually treated blindly with calcium and Vitamin D supplementation without PTH and vitamin D level monitoring. This usually results in a large number of patients who are either inadequately treated for secondary hyperparathyroidism or are pushed into adynamic bone disease status associated with serious CKD-MBD-related complications. The insufficient number of trained nephrologists all over the country also contributes to this issue. At the same time, lack of state funding for health care and low socioeconomic status of many patients leads to poor follow-up and compliance with the treatment protocols. Therefore, renal bone disease as a part of CKD-MBD needs special attention of all stakeholders of the healthcare system along with cooperation from the patients regarding compliance toward disease management protocols. [1],[13]

We conclude that our study suggests that at the initiation of hemodialysis, a significantnumber of patients have adynamic bone diseases (low PTH) as well as high turnover (high PTH) state, which indicate improper assessment and treatment of CKD-MBD at the pre-dialysis stage. Early assessment of renal bone disease is a crucial step in the management of CKD patients to prevent MBD-related serious complications.


   Acknowledgments Top


The authors are thankful to their dialysis unit staff for their hard work and professional commitment and for helping in data collection for this study.

Conflict of interest: None declared.

 
   References Top

1.
Chauhan V, Kelepouris E, Chauhan N, Vaid M. Current concepts and management strategies in chronic kidney disease-mineral and bone disorder. South Med J 2012;105:479-85.  Back to cited text no. 1
    
2.
Muntner P, Jones TM, Hyre AD, et al. Association of serum intact parathyroid hormone with lower estimated glomerular filtration rate. Clin J Am Soc Nephrol 2009;4:186-94.  Back to cited text no. 2
    
3.
Uhlig K, Berns JS, Kestenbaum B, et al. KDOQI US commentary on the 2009 KDIGO Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of CKD-Mineral and Bone Disorder (CKD-MBD). Am J Kidney Dis 2010;55:773-99.  Back to cited text no. 3
    
4.
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 2009;76 Suppl 113: S1-130.  Back to cited text no. 4
    
5.
Moe S, Drüeke T, Cunningham J, et al. Definition, evaluation, and classification of renal osteodystrophy: A position statement from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int 2006;69:1945-53.  Back to cited text no. 5
    
6.
Levin A, Bakris GL, Molitch M, et al. Prevalence of abnormal serum vitamin D, PTH, calcium, and phosphorus in patients with chronic kidney disease: Results of the study to evaluate early kidney disease. Kidney Int 2007;71:31-8.  Back to cited text no. 6
    
7.
Spasovski GB, Bervoets AR, Behets GJ, et al. Spectrum of renal bone disease in end-stage renal failure patients not yet on dialysis. Nephrol Dial Transplant 2003;18:1159-66.  Back to cited text no. 7
    
8.
Mathew S, Lund RJ, Strebeck F, Tustison KS, Geurs T, Hruska KA. Reversal of the adynamic bone disorder and decreased vascular calcification in chronic kidney disease by sevelamer carbonate therapy. J Am Soc Nephrol 2007;18:122-30.  Back to cited text no. 8
    
9.
London GM, Marchais SJ, Guérin AP, Boutouyrie P, Métivier F, de Vernejoul MC. Association of bone activity, calcium load, aortic stiffness, and calcifications in ESRD. J Am Soc Nephrol 2008;19:1827-35.  Back to cited text no. 9
    
10.
Changsirikulchai S, Domrongkitchaiporn S, Sirikulchayanonta V, et al. Renal osteodystrophy in Ramathibodi Hospital: Histomorphometry and clinical correlation. J Med Assoc Thai 2000;83:1223-32.  Back to cited text no. 10
    
11.
D'Haese PC, Spasovski GB, Sikole A, et al. A multicenter study on the effects of lanthanum carbonate (Fosrenol) and calcium carbonate on renal bone disease in dialysis patients. Kidney Int Suppl 2003;85:S73-8.  Back to cited text no. 11
    
12.
Ferreira A, Frazão JM, Monier-Faugere MC, et al. Effects of sevelamer hydrochloride and calcium carbonate on renal osteodystrophy in hemodialysis patients. J Am Soc Nephrol 2008;19:405-12.  Back to cited text no. 12
    
13.
Khan SS, Kazmi WH, Abichandani R, Tighiouart H, Pereira BJ, Kausz AT. Health care utilization among patients with chronic kidney disease. Kidney Int 2002;62:229-36.  Back to cited text no. 13
    

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Correspondence Address:
Rahmat Ullah Khan
Pakistan Atomic Energy Commission (PAEC) General Hospital, Sector H-11/4, Islamabad
Pakistan
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DOI: 10.4103/1319-2442.160227

PMID: 26178568

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