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(October), 2005 VOL 46, NO 4, SUPPL 1, OCTOBER 2005 CONTENTS American Journal of AJKD Kidney Diseases K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Children With Chronic Kidney Disease Tables............................................................................................................................... S1 Figures ............................................................................................................................. S1 Acronyms and Abbreviations........................................................................................ S2 Algorithms ....................................................................................................................... S3 Work Group Members..................................................................................................... S4 K/DOQI Advisory Board Members................................................................................. S5 Foreword.......................................................................................................................... S6 Introduction ..................................................................................................................... S8 Guideline 1. Evaluation of Calcium and Phosphorus Metabolism ............................ S12 Guideline 2. Assessment of Bone Disease Associated with CKD................................ S18 Guideline 3. Surgical Management of Osteodystrophy ............................................. S23 Guideline 4. Target Serum Phosphorus Levels.......................................................... S26 Guideline 5. Management of Dietary Phosphorus Intake in Children with CKD ...... S29 Guideline 6. Use of Phosphate Binders in CKD ......................................................... S32 Guideline 7. Serum Calcium and Calcium-Phosphorus Product .............................. S39 Guideline 8. Prevention and Treatment of Vitamin D Insufficiency and Vitamin D Deficiency in CKD Patients ................................................................................... S48 Guideline 9. Active Vitamin D Therapy in CKD Patients .......................................... S53 Guideline 9A. Active Vitamin D Therapy in Patients with CKD Stages 2-4 ........... S53 Guideline 9B. Active Vitamin D Therapy in Patients on Dialysis (CKD Stage 5) ... S57 Guideline 10. Dialysate Calcium Concentrations...................................................... S64 Guideline 11. Recommendations for the Use of Growth Hormone for Children with CKD .............................................................................................................. S68 Guideline 12. Aluminum Overload and Toxicity in CKD.......................................... S70 Guideline 13. Treatment of Aluminum Toxicity ....................................................... S79 Guideline 14. Treatment of Bone Disease in CKD ..................................................... S87 Guideline 14A. Hyperparathyroid (High-Turnover) Bone Disease ....................... S87 Guideline 14B. Rickets/Osteomalacia.................................................................... S87 Guideline 14C. Adynamic Bone Disease................................................................ S88 Guideline 15. Parathyroidectomy in Patients with CKD ........................................... S91 Guideline 16. Metabolic Acidosis.............................................................................. S94 Guideline 17. Bone Disease in the Pediatric Kidney Transplant Recipient ................ S96 Afterword ......................................................................................................................... S99 Biographical Sketches of Work Group Members ........................................................ S101 References....................................................................................................................... S103 Tables Table 1. Signs and Symptoms of Bone Disease in Children with CKD .......................................... S9 Table 2. Frequency of Measurement of PTH, Calcium, Phosphorus, Total CO2, and Alkaline Phosphatase by Stage of CKD........................................................................... S12 Table 3. Target Range of Serum PTH by Stage of CKD................................................................ S12 Table 4. Histological Features of High-Turnover Renal Osteodystrophy...................................... S19 Table 5. Histological Features of Low-Turnover Renal Osteodystrophy ...................................... S19 Table 6. Representative Normal Values for Serum Phosphorus, Total Calcium, Blood Ionized Calcium, and Alkaline Phosphatase Concentrations........................................... S26 Table 7. Dietary Reference Intakes of Phosphorus in Children..................................................... S29 Table 8. Steps to Calculate the Initial Binder Prescription ............................................................ S33 Table 9. Phosphorus-Binding Compounds .................................................................................... S33 Table 10. Recommendations for Calcium Intake ............................................................................ S40 Table 11. Calcium Content of Common Calcium-Based Binders ................................................... S41 Table 12. Low-Phosphorus, High-Calcium Foods .......................................................................... S42 Table 13. Partial List of Calcium-Containing Supplements ............................................................ S43 Table 14. Determining Calcium Requirements in Adults Aged 19-30 Years .................................. S45 Table 15. Recommended Supplementation for Vitamin D Deficiency/Insufficiency in Patients with CKD Stages 3-4 ......................................................................................... S48 Table 16. Serum Levels of PTH, Calcium, and Phosphate Required for Initiation of Oral Vitamin D Sterol Therapy, and Recommended Initial Doses in Patients with CKD Stages 2-4 ............................................................................................................... S53 Table 17. Initial Calcitriol Dosing Recommendations for Children on Maintenance Dialysis ....... S57 Table 18. Aluminum-Related Disorders: Features, Causes, and Considerations for Therapy ........ S71 Table 19. Frequency for Measurement of Serum Levels of Total CO2 ........................................... S94 Table 20. Frequency of Measurement of Calcium, Phosphorus, PTH, and Total CO2 after Kidney Transplantation.................................................................................................... S96 Figures Figure 1. Relationship between Serum iPTH Levels and CCR......................................................... S13 Figure 2. Summary ROC Analysis of Erosions on X-Ray as Diagnostic for Osteitis Fibrosa .......... S14 Figure 3. Summary ROC Analysis of Intact PTH for Diagnosis of High-Turnover Bone Disease... S15 Figure 4. Summary ROC Analysis of Intact PTH for Diagnosis of Low-Turnover Bone Disease ... S16 Figure 5. Meta-Analysis of Size of Effect on Serum Phosphorus Levels of Calcium Acetate versus Calcium Carbonate .................................................................................... S35 Figure 6. Meta-Analysis of Size of Hypercalcemic Effect of Calcium Carbonate versus Other Phosphate Binders.................................................................................................... S35 Figure 7. Meta-Analysis of Oral versus Intravenous Calcitriol on PTH Suppression....................... S62 Figure 8. Individual Study and Summary Effect sizes for the Effect of DFO Therapy on Bone Formation Rate .................................................................................................... S83 Figure 9. Individual Study and Summary Effect Sizes for the Effect of DFO Therapy on Bone Surface Aluminum Stain........................................................................................... S83 American Journal of Kidney Diseases, Vol 46, No 4, Suppl 1 (October), 2005: p S1 S1 Acronyms and Abbreviations 1st PTH-IMA First-generation parathyroid hormone immunometric assay 2° HPT Secondary hyperparathyroidism AIs Adequate intakes AVN Avascular necrosis BCG Bromocresol green method BFR Bone formation rate BMC Bone mineral content BMD Bone mineral density CaR Calcium-sensing receptors CAPD Continuous ambulatory peritoneal dialysis CaXP Calcium-phosphorus product CCR Creatinine clearance rate CKD Chronic kidney disease CRF Chronic renal failure DBP Vitamin D-binding protein DEXA Dual energy X-ray absorptiometry DFO Desferrioxamine DOQI Dialysis Outcomes Quality Initiative DRI Dietary Reference Intake EBCT Electron beam computed tomography EEG Electroencephalogram ESRD End-stage renal disease GFR Glomerular filtration rate GH, rhGH Growth hormone, recombinant human growth hormone ICMA Immunochemiluminometric assay IGF Insulin-like growth factor IRMA Immunoradiometric assay K/DOQI Kidney Disease Outcomes Quality Initiative MCV Mean cell volume MDRD Modification of Diet in Renal Disease MRI Magnetic resonance imaging NKF National Kidney Foundation PBM Peak bone mass PTH Parathyroid hormone QCT Quantitative computed tomography RDA Recommended dietary allowance RDI Recommended daily intake ROC Receiver operating characteristics SCFE Symptomatic proximal femoral slipped epiphyses SD Standard deviation VDR Vitamin D receptor VDRE Vitamin
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