Diagnosis and management of mineral metabolism in CKD

J Gen Intern Med. 2010 Jul;25(7):710-6. doi: 10.1007/s11606-010-1316-y. Epub 2010 Mar 30.


Background: Chronic kidney disease (CKD) affects over 26 million Americans and is frequently complicated early in its course by disordered mineral metabolism and metabolic bone disease. Since CKD-related bone loss is often indistinguishable from osteoporosis by standard bone densitometry, many CKD patients may be inappropriately treated with bisphosphonates rather than CKD-specific therapies.

Objective: To determine the prevalence of appropriate evaluation, diagnosis and management of metabolic bone disease among individuals with pre-dialysis CKD.

Design and participants: Retrospective cohort study using electronic medical records of 69,215 ambulatory patients seen in the primary care clinics of an academic medical center.

Measurements: Prevalence of CKD stages 3-4, frequency of diagnostic testing and treatment of metabolic bone disease.

Main results: Based on current diagnostic criteria and consistent with national data, CKD was present in 12% of the population. Bisphosphonates were used in 7.2% of patients, 20% of whom met criteria for CKD. Fewer than half of CKD patients underwent testing for parathyroid hormone (PTH) or 25-hydroxyvitamin D (25D) levels. Among those tested, vitamin D deficiency (25D <30 ng/ml) and secondary hyperparathyroidism (PTH >60 pg/ml) were present in 65% and 55%, respectively. Among patients with CKD, bisphosphonate use was nearly seven times as frequent as therapy with active vitamin D (12% vs. 1.7%, p < 0.0001), a primary treatment for CKD-associated metabolic bone disease.

Conclusions: Disordered mineral metabolism in CKD is common, under-diagnosed and under-treated. As a result, bisphosphonates may be prescribed inappropriately in patients with CKD.

Publication types

  • Comparative Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Bone Diseases, Metabolic / diagnosis*
  • Bone Diseases, Metabolic / epidemiology
  • Bone Diseases, Metabolic / therapy*
  • Cohort Studies
  • Disease Management
  • Electronic Health Records
  • Female
  • Humans
  • Kidney Failure, Chronic / diagnosis*
  • Kidney Failure, Chronic / epidemiology
  • Kidney Failure, Chronic / therapy*
  • Male
  • Middle Aged
  • Prevalence
  • Retrospective Studies