Consequences of the implementation of K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease in a population of patients on chronic hemodialysis.
BACKGROUND
After application of K/DOQI recommendations, a large proportion of our patients failed to reach the proposed targets. This study examined the causes of these findings.


METHODS
Patients (n=163) were compared in 2 periods (8 months before and after application of K/DOQI guidelines). Serum calcium (Ca), phosphorus (P), parathyroid hormone (PTH) and calcium x phosphate product (Ca x P); mean dialysate Ca content; mean doses of vitamin D; and average prescription of Ca-based phosphate binders and sevelamer in both periods were analyzed.


RESULTS
Prescription of Ca salts as phosphate-binding agents decreased and prescription of sevelamer increased in an attempt to maintain serum Ca levels between 8.4 and 9.5 mg/dL post-K/DOQI. Increased serum PTH levels were associated with decreased serum Ca levels (relative risk [RR] = 41.1, p<0.001) and increased serum P levels (RR=6.81, p<0.01). Use of dialysis fluids with Ca content of 2.5 mEq/L was associated with an increased risk of having PTH levels >300 pg/mL (RR=11.4, p<0.003). Vitamin D metabolites had to be discontinued in 26 patients (37.1% of those receiving them from study start) due to hyperphosphoremia or hypercalcemia post-K/DOQI; and serum PTH significantly increased (445.8 +/- 238.2 pg/mL vs. 715.2 +/- 549.5 pg/mL; p<0.001). Ninety-three patients (57%) did not receive vitamin D at study start; in 20 of those (21.5%), vitamin D had to be started post-K/DOQI.


CONCLUSIONS
Clinical guidelines do not appear to be sufficient to overcome all difficulties arising in daily management of these patients.
Arenas
María D
MD
Department of Nephrology, Perpetuo Socorro Hospital, Alicante, Spain. arenasd@perpetuosocorro.nehos.com
Alvarez-Ude
Fernando
F
Torregrosa
Vicente
V
Gil
María T
MT
Carretón
María A
MA
Moledous
Analía
A
Nuñez
Carlos
C
Devesa
Ramón
R
Albiach
Begoña
B
D000368:Aged; D001842:Bone and Bones / Q000378:metabolism*; D002118:Calcium / Q000097:blood; D002614:Chelating Agents / Q000008:administration & dosage; D012080:Chronic Kidney Disease-Mineral and Bone Disorder / Q000175:diagnosis* / Q000188:drug therapy* / Q000209:etiology; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D010281:Parathyroid Hormone / Q000097:blood; D010758:Phosphorus / Q000097:blood; D011073:Polyamines / Q000008:administration & dosage; D017410:Practice Guidelines as Topic; D006435:Renal Dialysis; D012189:Retrospective Studies; D000069603:Sevelamer; D014807:Vitamin D / Q000008:administration & dosage
D002614:Chelating Agents; C470125:PTH protein, human; D010281:Parathyroid Hormone; D011073:Polyamines; D014807:Vitamin D; D010758:Phosphorus; D000069603:Sevelamer; D002118:Calcium