Integral pharmacological management of bone mineral disorders in chronic kidney disease (part I): from treatment of phosphate imbalance to control of PTH and prevention of progression of cardiovascular calcification

Expert Opin Pharmacother. 2016 Jun;17(9):1247-58. doi: 10.1080/14656566.2016.1182155. Epub 2016 May 13.


Introduction: Chronic kidney disease-mineral and bone disorders (CKD-MBD), involving a triad of laboratory and bone abnormalities, and tissue calcifications, are associated with dismal hard-outcomes.

Areas covered: In two comprehensive articles, we review contemporary and future pharmacological options for treatment of phosphate (P) imbalance (this part 1) and hyperparathyroidism (part 2), taking into account CKD-accelerated atheromatosis/atherosclerosis and/or cardiovascular calcification (CVC) processes.

Expert opinion: Improvements in CKD-MBD require an integral approach, addressing all three components of the CKD-MBD triad. Individualization of treatment with P-binders and combinations of anti-parathyroid agents may improve biochemical control with lower incidence of undesirable effects. Isolated biochemical parameters do not accurately reflect calcium or P load or bone activity and do not stratify high cardiovascular risk patients with CKD. Initial guidance is provided on reasonable therapeutic strategies which consider the presence of CVC. This part reflects that although there is not an absolute evidence, many studies point to the need to improve P imbalance while trying to, at least, avoid progression of CVC by restriction of Ca-based P-binders if economically feasible. The availability of new drugs (i.e. inhibitors of intestinal transporters), and studies including early CKD should ultimately lead to clearer and more cost/effective clinical targets for CKD-MBD.

Keywords: CKD-MBD; Chronic kidney disease; calcium receptor; hyperparathyroidism; iron; phosphate; phosphate binders; vascular calcification; vitamin D.

Publication types

  • Review

MeSH terms

  • Bone Diseases / complications
  • Bone Diseases / drug therapy*
  • Bone Diseases / metabolism
  • Calcimimetic Agents / therapeutic use
  • Calcium / metabolism
  • Cardiovascular Diseases / complications
  • Cardiovascular Diseases / metabolism
  • Cardiovascular Diseases / prevention & control*
  • Disease Progression
  • Humans
  • Hyperparathyroidism / complications
  • Hyperparathyroidism / drug therapy*
  • Hyperparathyroidism / metabolism
  • Minerals / metabolism
  • Parathyroid Hormone / metabolism
  • Phosphates / deficiency
  • Phosphates / metabolism*
  • Renal Insufficiency, Chronic / complications
  • Renal Insufficiency, Chronic / drug therapy*
  • Renal Insufficiency, Chronic / metabolism
  • Risk Factors
  • Vascular Calcification / chemically induced
  • Vascular Calcification / prevention & control*


  • Calcimimetic Agents
  • Minerals
  • Parathyroid Hormone
  • Phosphates
  • Calcium