title: Analysis of renal bone disease treatment in dialysis patients.
abstract: End-Stage Renal Disease Network 11 initiated a renal osteodystrophy quality improvement activity in 1999. One component was the collection and assessment of dialysis facility renal osteodystrophy protocols, whereas another component was the analysis of bone disease-related medication use. Two hundred eighty-eight facilities were invited to submit protocols. A model bone disease and mineral metabolism protocol was developed as the standard for comparison. From the model protocol, an instrument was created to evaluate eight key areas (baseline screening of key laboratory data, dietary intervention, phosphate-binder use, vitamin D use, monitoring of key laboratory indicators, management of hypercalcemia, oversuppression of parathyroid hormone [PTH], and guidelines for both hemodialysis and peritoneal dialysis patients). A bone disease-related prescription survey was completed for 749 randomly selected patients. Survey information included vitamin D and phosphate-binder use and related laboratory values (calcium, phosphorus, intact PTH [iPTH], and calcium x phosphorus product). Although 45% of facilities had six or more points on the evaluation tool, protocols were still incomplete compared with the model. Mean facility-specific scores among the five states in the Network ranged from 1.0 to 5.9 (possible scores, 0 to 8). Most patients were prescribed a phosphate binder; however, 31.8% had average phosphorus levels greater than 6.0 mg/dL during the 3-month period. Only 58% of patients with average iPTH concentrations greater than 260 pg/mL were prescribed vitamin D. Of patients treated with vitamin D, 39% had iPTH concentrations less than 130 pg/mL. There is opportunity to improve renal osteodystrophy protocols in Network 11 and reinforce potential hazards of sustained hyperphosphatemia and hyperparathyroidism.
authors.affiliation: Renal Network of the Upper Midwest, ESRD Network 11, St Paul, MN, USA. cajohnson@pharmacy.wisc.edu
authors.forename: Curtis A
authors.initials: CA
authors.lastname: Johnson
authors.forename: James
authors.initials: J
authors.lastname: McCarthy
authors.forename: George R
authors.initials: GR
authors.lastname: Bailie
authors.forename: Jan
authors.initials: J
authors.lastname: Deane
authors.forename: Susan
authors.initials: S
authors.lastname: Smith
mesh_terms: D000465:Algorithms; D012080:Chronic Kidney Disease-Mineral and Bone Disorder / Q000150:complications / Q000188:drug therapy*; D002985:Clinical Protocols; D006801:Humans; D006934:Hypercalcemia / Q000150:complications; D007676:Kidney Failure, Chronic / Q000150:complications* / Q000628:therapy*; D028044:Phosphate-Binding Proteins / Q000627:therapeutic use; D006435:Renal Dialysis; D016896:Treatment Outcome; D014807:Vitamin D / Q000627:therapeutic use
chemical_list: D028044:Phosphate-Binding Proteins; D014807:Vitamin D