title: Diagnosis and management of mineral metabolism in CKD.
abstract: 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.
  
  
  METHODS
  Retrospective cohort study using electronic medical records of 69,215 ambulatory patients seen in the primary care clinics of an academic medical center.
  
  
  METHODS
  Prevalence of CKD stages 3-4, frequency of diagnostic testing and treatment of metabolic bone disease.
  
  
  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.
authors.affiliation: Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. ibhan@partners.org
authors.forename: Ishir
authors.initials: I
authors.lastname: Bhan
authors.forename: Anil
authors.initials: A
authors.lastname: Dubey
authors.forename: Myles
authors.initials: M
authors.lastname: Wolf
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001851:Bone Diseases, Metabolic / Q000175:diagnosis* / Q000453:epidemiology / Q000628:therapy*; D015331:Cohort Studies; D019468:Disease Management; D057286:Electronic Health Records; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000175:diagnosis* / Q000453:epidemiology / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D012189:Retrospective Studies