title: Management of CKD-MBD in non-dialysis patients under regular nephrology care: a prospective multicenter study.
abstract: BACKGROUND
  Knowledge about mineral bone disorder (MBD) management in non-dialysis chronic kidney disease (ND-CKD) patients is scarce, although essential to identifying areas for therapeutic improvement.
  
  
  METHODS
  We prospectively evaluated current management of CKD-MBD in two visits, performed 6 months apart, in 727 prevalent ND-CKD stage 3b-5 patients from 19 nephrology clinics. Therapeutic inertia was defined as lack of treatment despite hyperphosphatemia and/or hypocalcemia, and/or hyperparathyroidism. The primary endpoint was the prevalence of achieved target for CKD-MBD parameters and related treatments (phosphate binders, vitamin D and calcium supplements). The secondary endpoint was the assessment of prevalence and clinical correlates of therapeutic inertia.
  
  
  RESULTS
  Over 65 % of patients did not reach parathormone (PTH) targets, while 15 and 19 % did not reach phosphate and calcium targets, respectively. The proportion of untreated patients decreased from stage 3b to 5 (at baseline, from 60 to 16 %, respectively). From baseline to the 6-month visit, the achievement of targets remained stable. Low protein diet was prescribed in 26 % of patients, phosphate binders in 17.3 % (calcium-based binders 15.5 %, aluminium binders 1.8 %), and vitamin D in 50.5 %. The overall prevalence of therapeutic inertia at the 6-month visit was 34.0 % (for hyperphosphatemia, 54.3 %). Compared to CKD stage 3, the likelihood of therapeutic inertia was 40 and 68 % lower at stage 4 and 5, respectively.
  
  
  CONCLUSIONS
  PTH, calcium and phosphate targets were not reached in a significant proportion of patients. One-third of patients with at least one MBD parameter not-at-target remained untreated. Therapeutic inertia regarding CKD-MBD treatment may be a major barrier to optimizing the prevention and cure of CKD-MBD.
authors.affiliation: Nephrology and Dialysis Unit, Ospedale San Carlo Borromeo, University of Milano, via Pio II, 3, 20153, Milan, Italy. maurizio.gallieni@fastwebnet.it.
authors.forename: Maurizio
authors.initials: M
authors.lastname: Gallieni
authors.affiliation: Second University of Naples, Naples, Italy.
authors.forename: Nicola
authors.initials: N
authors.lastname: De Luca
authors.affiliation: University of Messina, Messina, Italy.
authors.forename: Domenico
authors.initials: D
authors.lastname: Santoro
authors.affiliation: Dolo General Hospital, Dolo-Venice, Italy.
authors.forename: Gina
authors.initials: G
authors.lastname: Meneghel
authors.affiliation: Ospedali di Savigliano e Ceva, ASL Cuneo 1, Cuneo, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Formica
authors.affiliation: Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Grandaliano
authors.affiliation: S.M. Annunziata Hospital, Florence, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Pizzarelli
authors.affiliation: SS Annunziata Hospital, Sassari, Italy.
authors.forename: Maria
authors.initials: M
authors.lastname: Cossu
authors.affiliation: University of Turin, Turin, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Segoloni
authors.affiliation: S. Maria della Misericordia Hospital, Perugia, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Quintaliani
authors.affiliation: S. Camillo Forlanini Hospital, Rome, Italy.
authors.forename: Salvatore
authors.initials: S
authors.lastname: Di Giulio
authors.affiliation: University Federico II, Naples, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Pisani
authors.affiliation: Ospedale San Paolo, Civitavecchia, Italy.
authors.forename: Moreno
authors.initials: M
authors.lastname: Malaguti
authors.affiliation: C. Poma Hospital, Mantova, Italy.
authors.forename: Cosimo
authors.initials: C
authors.lastname: Marseglia
authors.affiliation: Ospedale Fracastoro, San Bonifacio, Italy.
authors.forename: Lamberto
authors.initials: L
authors.lastname: Oldrizzi
authors.affiliation: Second University of Naples, Naples, Italy.
authors.forename: Mario
authors.initials: M
authors.lastname: Pacilio
authors.affiliation: Second University of Naples, Naples, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Conte
authors.affiliation: Fondazione IRCSS Policlinico S. Matteo and University of Pavia, Pavia, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Dal Canton
authors.affiliation: Second University of Naples, Naples, Italy.
authors.forename: Roberto
authors.initials: R
authors.lastname: Minutolo
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015415:Biomarkers / Q000097:blood; D001851:Bone Diseases, Metabolic / Q000097:blood / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology; D002118:Calcium / Q000097:blood / Q000627:therapeutic use*; D002614:Chelating Agents / Q000627:therapeutic use*; D018753:Diet, Protein-Restricted; D019587:Dietary Supplements; D005260:Female; D006801:Humans; D007558:Italy; D008297:Male; D008875:Middle Aged; D009398:Nephrology; D010281:Parathyroid Hormone / Q000097:blood; D010710:Phosphates / Q000097:blood; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D051436:Renal Insufficiency, Chronic / Q000097:blood / Q000150:complications / Q000175:diagnosis / Q000628:therapy*; D013997:Time Factors; D016896:Treatment Outcome; D014807:Vitamin D / Q000097:blood / Q000627:therapeutic use*
chemical_list: D015415:Biomarkers; D002614:Chelating Agents; C470125:PTH protein, human; D010281:Parathyroid Hormone; D010710:Phosphates; D014807:Vitamin D; D002118:Calcium
keywords: Calcium; Chronic kidney disease; PTH; Phosphate; Therapeutic inertia; Treatment; Vitamin D