title: Systematic review of the evidence underlying the association between mineral metabolism disturbances and risk of fracture and need for parathyroidectomy in CKD.
abstract: BACKGROUND
  Chronic kidney disease (CKD) is associated with such complications as fractures and the need for parathyroidectomy. Mineral metabolism control in patients with CKD has been poor. Studies have assessed fractures and parathyroidectomy risk with mineral disturbances, but with considerable diversity in methods. Thus, a systematic review was conducted to assess method or clinical heterogeneity by comparing the design, analytical techniques, and results of studies.
  
  
  METHODS
  Systematic review of the MEDLINE, EMBASE, and Cochrane databases between 1980 and December 2007.
  
  
  METHODS
  Patients with CKD or dialysis patients.
  
  
  METHODS
  Observational and clinical trials investigating the risk of fractures or parathyroidectomy with mineral disturbances.
  
  
  METHODS
  Mineral metabolism variables (phosphorus, calcium, and parathyroid hormone [PTH] levels).
  
  
  RESULTS
  Fractures, need for parathyroidectomy.
  
  
  RESULTS
  9 studies were identified that assessed fractures (n = 6) or need for parathyroidectomy (n = 3). Data for fractures or parathyroidectomy risk in predialysis patients are absent. Diversity across studies was observed in populations, methods of exposure assessment, adjusted covariates, and reference mineral levels used in risk estimation. A significant fracture risk was observed with increasing PTH levels. However, additional data are required to understand fracture risk with changes in phosphorus or calcium levels. Data supported greater parathyroidectomy risk with increasing PTH, phosphorus, or calcium levels.
  
  
  CONCLUSIONS
  Clinical and method heterogeneity across studies precluding the quantitative synthesis of data.
  
  
  CONCLUSIONS
  Serious limitations were observed in the number, quality, and method rigor of studies. Despite heterogeneity across studies, data suggest a significant parathyroidectomy risk with mineral disturbances and a fracture risk with increasing PTH levels in dialysis patients. Additional high-quality data for risk of fractures or parathyroidectomy with changes in phosphorus, calcium, or PTH levels is required to highlight the importance of managing such common, but subclinical, conditions as mineral metabolism disturbances.
authors.affiliation: Guy's Hospital, London, UK. goldsmith@london.com
authors.forename: David
authors.initials: D
authors.lastname: Goldsmith
authors.forename: Prajesh
authors.initials: P
authors.lastname: Kothawala
authors.forename: Arpi
authors.initials: A
authors.lastname: Chalian
authors.forename: Myriam
authors.initials: M
authors.lastname: Bernal
authors.forename: Sean
authors.initials: S
authors.lastname: Robbins
authors.forename: Adrian
authors.initials: A
authors.lastname: Covic
mesh_terms: D019317:Evidence-Based Medicine / Q000379:methods / Q000639:trends; D050723:Fractures, Bone / Q000209:etiology / Q000378:metabolism* / Q000601:surgery*; D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications / Q000378:metabolism* / Q000601:surgery*; D008903:Minerals / Q000378:metabolism*; D016105:Parathyroidectomy / Q000706:statistics & numerical data / Q000639:trends; D012307:Risk Factors
chemical_list: D008903:Minerals